A Lateral violence: Why it’s serious and what OR managers can do

Transcription

The monthly publication
for OR decision makers
December 2007
Vol 23, No 12
Leadership
ASC section on page 23.
In this issue
Senate bill seeks to air
implant pricing . . . . . . . . . . . . . .5
LEADERSHIP.
Opening managers’ eyes
to lateral violence . . . . . . . . . . .10
Counts off in 1 in 8
general surgery cases . . . . . . . .11
MANAGING PEOPLE.
Which candidates are
the keepers? . . . . . . . . . . . . . . . .14
PATIENT SAFETY.
A time-out tool helps to
improve compliance at the
patient’s bedside . . . . . . . . . . . .15
OR THROUGHPUT.
Are your operating rooms
‘efficient’? . . . . . . . . . . . . . . . . . .16
MANAGING TODAY’S
OR SUITE.
Managing people a theme
at conference . . . . . . . . . . . . . . .21
AMBULATORY SURGERY
CENTERS.
CMS sets final 2008 ASC
payment rates . . . . . . . . . . . . . .23
AMBULATORY SURGERY
CENTERS.
Tips for a successful hire
in your ASC . . . . . . . . . . . . . . . .25
OR Manager subject
index 2007 . . . . . . . . . . . . . . . . . .27
AT A GLANCE . . . . . . . . . . . . .32
Lateral violence: Why it’s serious
and what OR managers can do
nurse hides a surgeon’s favorite
instrument when a substitute fills
in as the scrub. A circulator does
not tell a new nurse who is scrubbed that
she knows the shunt the surgeon selected
has fallen on the floor. A newly hired RN
who was previously a scrub tech is
shunned by both camps. Is this just life in
the OR? Is it part of a nurse’s rite of passage? Or is it something more insidious—
bullying?
Research suggests these behaviors are
prevalent and drive nurses away. The
behaviors go by several names: lateral or
horizontal violence, nurse-to-nurse bullying, sabotage, or the popular phrase,
“nurses eating their young.”
The nursing literature over the past 20
years has documented lateral violence
and its effects. Some researchers see a con-
A
nection between nurse-to-nurse bullying
and the behavior of oppressed groups.
The thinking is that health care organizations tend to be hierarchies headed by
physicians and administrators. A hierarchy places power in the hands of a few
people at the top and disempowers nurses, who take out their aggressions on one
another.
Bullying is especially serious for newly
licensed nurses, says researcher Martha
Griffin, RN, PhD, because it keeps them
from asking questions, validating their
knowledge, and feeling like they fit in—
all necessary for them to build their
knowledge and become part of the organization.
She has cataloged 10 behaviors that
characterize lateral violence (sidebar, p 7).
Continued on page 7
Managing people
Mastering a steep learning curve:
Trends in perioperative orientation
solid orientation is a cornerstone
for successful perioperative nursing. Choosing the right candidates
and giving them the knowledge and skills
to adapt to the surgical environment are
essential to safe practice and to retaining
staff. The learning curve for perioperative
nursing is steeper than ever— 83% of hospitals are hiring RNs without OR experience, and 55% are hiring new graduates,
according to this year ’s OR Manager
Salary/Career Survey. We interviewed
perioperative directors and educators
from 5 organizations about orientation
and how they prepare new recruits. And
because they often don’t have OR experience to go by, we also asked how they
select candidates they believe have the
A
right qualities to become successful perioperative nurses (page 14).
Among the challenges:
• balancing the need for classroom education with an introduction to clinical
practice
• getting orientees up to speed as quickly as possible while still giving them a
grounding in the specialties
• building a bridge to practice by combining practical skills with adult learning and nursing theories
• collaborating across a hospital system
for perioperative orientation
• seeking solutions for orienting nurses
to constantly changing technology.
Continued on page 12
2
Please see the ad for
MEGADYNE
in the OR Manager print version.
Upcoming Publisher’s Note
Periop process for
anticoagulant therapy
What’s needed to meet the Joint
Commission’s new patient safety goal
requirement?
MRSA protocols for surgery
Should preoperative patients be
screened for MRSA? What other steps
should be taken?
December 2007
Vol 23, No 12
OR Manager is a monthly publication for
personnel in decision-making positions in
the operating room.
Elinor S. Schrader: Publisher
Patricia Patterson: Editor
Judith M. Mathias, RN, MA:
Clinical editor
Kathy Shaneberger, RN, MSN, CNOR:
Consulting editor
Karen Y. Gerhardt: Art director
OR Manager (USPS 743-010), (ISSN 8756-8047)
is published monthly by OR Manager, Inc,
1807 Second St, Suite 61, Santa Fe, NM
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OR Manager is indexed in the Cumulative
Index to Nursing and Allied Health
Literature and MEDLINE/PubMed.
Copyright © 2007 OR Manager, Inc. All rights
reserved. No part of this publication may be
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08071. Telephone: 856/256-2300; Fax: 856/
589-7463. John R. Schmus, national advertising manager. E-mail: [email protected]
December 2007
he ringing was persistent. Santa put
down his sudoku puzzle and
picked up his new iPhone.
“Don’t forget that you were going to
cut the grass today,” reminded Mrs.
Claus.
“Mow the what?” Santa exclaimed.
“Remember, with global warming, our snow has disappeared, and
we’ve replaced it with grass. The
snow blower makes a lovely container for my herb garden; I do
love the smell of basil.”
Santa mused: ‘The reindeer like
to nibble the grass, but it is tough to
get the big sled up in the air without
snow.”
“You could take the helicopter,” suggested Mrs. Claus.
“No, it is worse than a Hummer with
all the fuel it uses. Besides, it wakes up
everyone in the neighborhood when I
land on the roof.”
“Well, let me see if I can find some
snow on eBay for Christmas Eve so that
you and the reindeer can go on your
appointed rounds,” responded Mrs.
Claus. “Do you have your list ready?” she
asked.
“Yes,” responded Santa. “And I have
some terrific new presents.
“For parents, I am bringing lead-testing
kits for the toys under the tree that may
have been made in China. All parents will
want to test the toys their children receive
to make sure they are lead-free and safe.
“As a stocking stuffer, I am giving all
the children gift-wrapped alcohol-based
sanitizers (no triclosan) to tuck in their
backpacks to help avoid MRSA. Even
though the concern about MRSA in
schools is probably overblown, the scare
can help to reinforce the many benefits of
good handwashing.
“For those who must share public
space with loud incessant cell-phone talkers, I have special cell-phone jammers that
silence those calls.”
“They are illegal, you know,” commented Mrs Claus, who reads The New
York Times every day.
Santa reviewed his list. “With health
care reform coming up as the hottest election issue, there is going to be a great deal
of false information bandied about by
politicians, interest groups, and people
who are not well informed or who have
their agendas.
T
OR Manager Vol 23, No 12
“As you know, since we both had
bariatric surgery a number of years ago,
we have been admirers and friends of the
nurses and doctors that work in the OR.
That procedure made a great deal of difference in our lives.
“I hope that my friends in health care,
especially those in the OR, will be
informed and help their friends and colleagues understand the health care reform
issues and the solutions that will be discussed. So I am giving them this high-tech
false-information detection device. When
it detects false information, misleading
statements, and other nonsense, a red light
starts flashing, and it emits a loud noise
consisting of blah, blah, blah that overrides the speaker or other source.”
“That’s probably illegal, too,” sighed
Mrs Claus. “But what is that large box that
you are wrapping?”
“This is a special present for our leadership in Washington. It contains wisdom
and compassion that I hope they will use
as they move forward on health care
reform as well as other issues that we are
concerned about.
“Like precious jewels, the holidays are
many-faceted. For some it is a very religious time, for others it means gathering
with families, giving (and receiving) gifts,
or joining with friends for social gatherings.
“For me, I enjoy bringing fun and
laughter to children and adults alike.”
From Santa . . . and those of us at OR
Manager, enjoy the holidays and welcome
the New Year.
—Ellie Schrader
3
4
SKYTRON INC.
Senate bill seeks to air implant pricing
edical device companies would
have to file reports with the government on prices for all implants
sold, under a bill (S 2221) introduced Oct
23. The sponsors, Senators Arlen Specter of
Pennsylvania and Charles Grassley of
Iowa, both Republicans, say their aim is to
make transparent the prices manufacturers
charge hospitals participating in public programs like Medicare and Medicaid.
“The device makers actually prohibit
hospitals from disclosing the price of a
medical device to others. So hospitals have
no idea what is a fair price,” Senator
Grassley said. “This is a major reason why
many hospitals pay absurdly more than
others for the same medical device.”
Grassley said he is concerned because
device costs, which are rising 8% to 15% a
year, are taking up more of the Medicare
payment, which means hospitals have less
to spend on other aspects of care such as
staffing. It’s also causing Medicare spending to rise “faster than it should” if hospitals pay more than the fair market price
for implants.
Whether hospitals may compare
implant prices has led to lawsuits. Last
year, the nonprofit ECRI Institute sued
Guidant Corporation, whose cardiac
rhythm business has since merged with
Boston Scientific, over the right to publish
price comparisons of Guidant devices,
M
“
Hospitals have
no idea what is
a fair price.
“
such as pacemakers and internal defibrillators, as part of a service to subscribers.
Guidant countersued, saying ECRI
Institute had “tortiously interfered” with
its contracts with customers and had misappropriated “trade secrets” in obtaining
Guidant prices, which it considers confidential, from hospitals. Court-mandated
settlement discussions were underway in
early November. If the discussions fall
through, the case will proceed to trial.
Earlier in 2006, Aspen Healthcare
Metrics, a consulting unit of the group
purchasing organization MedAssets, settled a lawsuit by Guidant alleging that
Aspen illegally induced hospitals to violate the company’s confidential pricing
agreements for use in its consulting
engagements.
Senator Specter said he’d received let-
Advisory Board
William R. Anton, RRT
Business director, surgical services; Director,
value analysis, University of Washington
Medical Center, Seattle
Amy Bethel, RN, MPA, CNA
Executive director, surgical services, Iowa
Health, Des Moines
Mark E. Bruley, EIT, CCE
Vice president of accident & forensic
investigation, ECRI, Plymouth Meeting,
Pennsylvania
Ramon Berguer, MD
Chief of surgery, Contra Costa Regional Medical
Center, Martinez, California
Helen K. Crouch, RN, MPH, CIC
Director, infection control & epidemio-logy
services; Infection control consultant for Army,
Great Plains Regional Command, Brooke Army
Medical Center, San Antonio, Texas
Marion L. Freehan, RN, MPA/HA, CNOR
Nurse director, main operating rooms,
Massachusetts General Hospital, Boston
Jo Harbaugh, RN, BS, CGRN
EndoSite advisor, Olympus America Inc
Normal, Illinois
Kenneth Larson, MD
Trauma surgeon, burn unit director,
Mercy St John’s Health Center,
Springfield, Missouri
William J. Mazzei, MD
Medical director, perioperative services,
University of California, San Diego
Mary M. Murphy, RN, BSN, CNOR
Director, surgical services, Munson Medical
Center, Traverse City, Michigan
Susan Nielsen, RN, MSA, CNOR
Director, Central Processing Department, William
Beaumont Hospital, Royal Oak, Michigan
Franklin Dexter, MD, PhD
Associate professor, Department of
Anesthesia, University of Iowa, Iowa City
Barbara Pankratz, RN, MSN
Director, surgical services, University of
Wisconsin Hospital & Clinics, Madison
Mary Diamond, RN, MBA, CNOR
Director of surgical services, Tri-City Medical
Center, Oceanside, California
Ena M. Williams, RN, BS
Nursing director, perioperative services,
Yale-New Haven Hospital, New Haven,
Connecticut
December 2007
ters from hospitals, consumer groups,
employers, and journalists about the secrecy of pricing for products like hip and
knee implants and pacemakers.
A challenge to implement
A New York hospital wrote him that
it spends about $300 million a year on
supplies. Though pacemakers and joint
implants account for only 3% of the
items the hospital buys, these devices
account for about 40% of the total
spending.
An analyst for Wachovia told
investors in October that a Washington,
DC, consultant gave the bill about 50%
odds of passing, noting that Senator
Grassley is powerful and works across
party lines. (There is no Democratic
cosponsor.)
Though he could not comment on
the pending litigation, Jeffrey Lerner,
PhD, president and CEO of ECRI
Institute, says he thinks the legislation
is promising.
“For almost any other major purchase, like a house, customers are able
to compare prices to help them make a
decision. It would be very beneficial to
bring that same shopping power into
health care purchasing.”
If passed, the bill would be challenging to implement. Implants have many
components, with different parts used
for individual patients, making it difficult to compare prices for constructs.
The government would need to determine how to classify the parts.
Under the bill, pricing would be
posted on the Internet. Manufacturers
who failed to report or misrepresented
price data would be assessed penalties
of $10,000 to $100,000. v
Writing to Congress
To comment on S 2221, the
Transparency in Medical Device
Pricing Act of 2007, you can send
an e-mail through your Congress
member’s website. Senators are
listed at www.senate.gov. House
members are at www.house.gov.
To download the bill and check its
status, enter the bill number at the
government’s website, Thomas, at
http://thomas.loc.gov.
5
6
ADVANCED STERILIZATION PRODUCTS
Leadership
Continued from page 1
“No other area in the hospital has a
higher probability of lateral violence than
the operating room,” says Griffin, who is
director of nursing professional development at Brigham & Women’s Hospital in
Boston and was a certified perioperative
nurse early in her career. “People from the
operating room call me the most, and I
understand it because I’ve lived it.”
There’s consensus that lateral violence
needs to be stopped. It’s not just inhumane—it has a corrosive effect on nurse
recruitment and
retention. It also
affects patient
safety. Experts
agree communication breakdowns and lack
of teamwork
are a root cause
of errors. If
nurses are afraid to speak up because they
fear being bullied by fellow nurses and
physicians, patients can be harmed.
Nurse directors and managers play a
pivotal role in defusing lateral violence.
“Directors carry the culture code of
the organization. They are responsible by
what they ignore or what they pay attention to—they set the standard.” says
Kathleen Bartholomew, RN, MN, author
of Ending Nurse-to-Nurse Hostility: Why
Nurses Eat Their Young and Each Other
(HCPro, 2006).
Is lateral violence increasing?
There are no studies documenting
whether bullying is increasing, but “if you
ask nurses about it compared with 10 or
15 years ago, they will say it is more common,” says Bartholomew. She became
interested in lateral violence after she
entered nursing at age 38 and experienced
it herself and later observed it as nurse
manager of a 57-bed orthopedic unit in a
large hospital.
She thinks the cost cutting that began
in hospitals in the late 1990s is a factor.
Shrinking resources, inefficient systems,
and managers’ broader span of control
have fueled stress, she believes.
“Nurses are the last line of defense
between patients and the system, and they
take more on themselves because we’re
never going to say no,” she says.
Plus, with more nurses working 12hour shifts, they no longer have time to go
December 2007
“
Nurses
need skills
to address
conflict.
“
out after work. They have less chance to
socialize and bond.
Coupled with social changes like more
single parents, more people working
longer hours each a week, and longer
commutes, people are carrying a heavier
load of stress.
A role for nurse leaders
Though nurse managers and directors
are stretched themselves, Bartholomew
urges them to realize “this is not small
stuff—the camaraderie and ability to communicate on your unit are mandatory for
teamwork.”
To address lateral violence, managers
need training to make sure they have the
needed skills, according to Karen M. Stanley,
MS, APRN, BC, and Mary M. Martin, DNS,
ARNP, of the Medical University of South
Carolina (MUSC) in Charleston, who are
also studying lateral violence.
“Participants reported over and over
that they believed their nurse manager
was aware of the behavior but did not take
action to stop it,” they say. They have
developed a survey to measure lateral violence, which is slated for publication in
Issues in Mental Health Nursing.
What we know works
Griffin published a well-known study
on lateral violence in 2004 in which 26
newly licensed nurses were taught about
lateral violence. They learned about ways
to respond to common forms of lateral
violence, with laminated cue cards as
reminders.
A year later, in focus groups, they
were asked about their experience with
lateral violence, use of the cue cards, and
their socialization. Almost all (96%) had
seen lateral violence during the year, and
46% said it was directed at them. All had
responded to the incidents, though they
said it was difficult. But the outcome was
that the lateral violence stopped.
Retention for the whole group of 62
The 10 most
frequent forms of
lateral violence
in nursing
Listed by frequency.
1. Nonverbal innuendo (raising of eyebrows, making faces)
2. Verbal affront (covert or overt snide
remarks, lack of openness, abrupt
responses)
3. Undermining activities (turning
away, not available)
4. Withholding information (practice
or patient)
5. Sabotage (deliberately setting up a
negative situation)
6. Infighting (bickering with peers)
7. Scapegoating (attributing all that
goes wrong to one individual)
8. Backbiting (complaining to others
about an individual and not speaking directly to that individual)
9. Failure to respect privacy
10. Broken confidences
Source: Reprinted with permission from
Griffin M. J Contin Educ Nurs.
2004;35(6):257-163. Adapted from Duffy
E. Collegian: J Royal Coll of Nurs
Australia. 1995;2(2):5-17; Farrell G A,
J Adv Nurs.1997; 25:501-508; McCall E.
Lamp.1996;53(3):28-29; McKenna B G,
et al, J Adv Nurs. 2003;42:90-96.
newly licensed nurses in that year was
91%, compared to a national rate of 40%
to 60% in other studies.
For the past 3 or 4 years, education on
lateral violence has been included in the
orientation of all nurses new to Brigham &
Women’s. Nursing staff also receive 1 hour
of education during annual “competency
days” given by nursing units. The education includes a short video illustrating incidents that have actually happened at the
hospital followed by a 10- to 15-minute
discussion.
Griffin is conducting a 2-year study
designed to measure the perception of nurses’ workplace behavior and the perceived
impact of education on lateral violence.
What can managers do?
This is advice from experts on lateral
Continued on page 9
7
8
SPECTRUM SURGICAL INSTRUMENTS
Leadership
Lateral violence in the OR
Examples from OR Manager readers:
I worked with a nurse who actually once
risked the patient to make herself look good
and me look bad. We were doing a carotid,
and I was scrubbed. I had a set of Javid
shunts on my field, and before the incision,
the surgeon looked at all of them and tied a
suture around the one he wanted. He told
us he didn’t think he would need it, but if
he did, he would need it fast and didn’t
want to have to wait for me to find it.
The case started, then, yes, he needed the
shunt. I reached on my back table, but it
wasn’t there. As I was frantically searching, with the surgeon pretty angry with
me, my circulator buddy reached into her
pocket, pulled out the shunt with the string
around it, dangled it in front of all of us
and said,”Oh, doctor, look what I found on
the floor after you draped!”
All that time she knew the shunt had
fallen off my table; she was present and listening when the surgeon explained why he
would need it fast. Yet she didn’t bother to
let us know she found it on the floor.
My manager was in the room. While this
nurse was dangling the shunt in front of all
of us, my manager went to the vascular
cart, grabbed another shunt and got it on
the field pronto, so thankfully, the patient
was okay.
The surgeon didn’t stop fussing at me for
the rest of the case because I had dropped
the shunt and didn’t realize it. As the circulator knew would happen, the surgeon did
not hold her responsible at all.
—Director of surgical services
violence and on ways managers can intervene to help their staffs.
Educate yourself
“Educate yourself about lateral violence and why it exists,” Bartholomew
advises.
“As a manager or director, you are
charged to see that your key people, your
managers or your charge nurses, are educated, can handle conflict, and can set a
standard of professional behavior.”
One thing every nurse can do: Never
be a silent witness.
“If you can do only one thing to lower
the hostility, you should stop listening to
December 2007
I was working for a supplemental
staffing agency. My first assignment
allowed me to experience lateral violence
first-hand while in the scrubbing role. The
surgeon had 2 favorite instruments that
were essential for him to complete his
planned surgery—diamond jaw Metzenbaum scissors and a diamond jaw needle
holder. His favorite circulating nurse was
gone for the day. I made a request for the
instruments, but they were nowhere to be
found. The case was completed with an
unhappy surgeon who voiced my incompetence to the rest of the team and the supervisors. Two weeks later, I was in the same
scenario, except this time his favorite circulator was there. I again requested the diamond jaw instruments. The circulator
retrieved both, the surgeon was happy, and
the procedure was completed. Then the surgeon explained to the circulator that during
his last case, the instruments were nowhere
to be found. The circulator stated she didn’t
understand the problem because the instruments were right where they belonged.
Where they had really been was in her locker.
—Former perioperative director
Shortly after graduating in 1999, I took a
job as a circulator in the OR. This seemed
to be a natural extension of my previous 9
years of experience as a scrub tech. What I
didn’t understand going into the job is that
the hospital had an unwritten hierarchy.
The OR had a locker/lounge area that
was used by all female personnel at the
beginning of the shift, but only scrub techs
used it during the day as a lounge area.
nurses bad-mouth other nurses,” she says.
“Gossiping can’t exist without an audience.”
Examine your own leadership style
Adopt a style of leadership that moves
away from top-down authority toward
consensus building, Griffin advises. Give
nurses more autonomy over their practice
through structures such as shared governance. “The more you empower them, the
less victimization there will be,” she says.
Set behavior standards
Griffin outlines expected professional
behaviors in her 2004 article.
The Medical University of South
Carolina has standards of behavior for all
employees based on core values. These
The main lounge/break room was used by
the OR nurses. No one explained the idiosyncrasies of the OR setup to me during
my orientation.
My preceptor introduced me to everyone
as a scrub tech turned circulator. After
those introductions, I was even more displaced. I was never made to feel welcome in
the “nurses’” lounge. When I would enter,
all conversation would quickly become a
low simmer rather than the previous boisterous engagements. I was constantly whispered about in that lounge, pointed to, and
my name was often brought up loudly during those whispering conversations.
I tried to use the “scrub” lounge a few
times and found that when I entered the
room, most of the scrubs either ignored me
or fled to other areas of the OR.
My preceptor never took the opportunity
to show me how things should be done or
how to prep correctly. Instead, she took
every opportunity to throw me into a situation where I was not totally comfortable,
and then scold me when I didn’t do things
the “right way.” She would often tell me
that since our room or case was delayed, I
should take a break. As soon as I would take
a 5- to 10-minute break, she would stand in
the hall upon my return and scold me by
saying loudly, “Where have you been?“
When I approached my director, she said
that she preferred for the staff to handle
their own difficulties.
—Nurse manager, outpatient
endoscopy center
include accountability, respect, excellence,
and adaptability. Each value has expected
behaviors, and all are reviewed with each
employee. Employees are asked to sign a
commitment to uphold the standards,
which is included in their personnel
record, says Stanley. They are evaluated on
adherence to the standards and rewarded
by merit pay. Employees can choose not to
sign, but the manager explains they will
still be held to the standards.
Educate managers
Stanley recommends including education about lateral violence in regular educational offerings for charge nurses and
preceptors.
9
Leadership
Opening managers’ eyes to lateral violence
workshop using real clinical narratives helps nurse managers
learn about lateral violence at a
community hospital in the Northeast.
The hospital has also adopted a policy on
lateral violence, which is in the early
stages of implementation.
Donna DeRobbio, RN, MSN, collected
the narratives as part of a research study
she conducted on lateral violence at
Westerly Hospital, Westerly, Rhode Island,
under a grant from the University of
Rhode Island.
“Because these are real incidents, it’s an
effective way to introduce the subject of
lateral violence,” she says.
The goal of the workshop is to raise
consciousness, assist managers in identifying lateral violence, and encourage them
to think about the problem.
“You want managers to learn to see
patterns of behavior. This is not judging
someone on a personal level for having a
bad day,” she says. “It’s about the impact
on patient care.”
A
Managers discuss narratives
The workshop is typically conducted
for a group of 8 nurse managers, who are
divided into small groups, preferably with
others they don’t know. Each group is
assigned one of the narratives (sidebar).
The group reads the narrative, and members discuss them. They then respond to
the following questions:
• What questions must the nurse have
had at this moment? How did the
other person(s) present influence the
nurse’s understanding of what happened?
• Who was there to help the nurse?
• What would you hope the nurse
learned from this experience?
Each group appoints a leader to report
its findings. Each participant is also asked
to reflect on the following questions on his
or her own:
• How did this exercise influence your
understanding of what it means to be a
nurse?
• How does it make you feel about your
practice?
The clinical narratives have been more
effective in educating managers than a lecture would be, DeRobbio observes. v
10
Nurses tell their stories
Actual incidents from Westerly
Hospital, Westerly, Rhode Island.
n I am a nurse on evenings. I noted on a
patient’s MAR [medication administration record] that there was a 5 am blood
sugar that was not covered with sliding
scale insulin, and no notation had been
made. As per hospital policy, I filled out
a variance. Several days later, the per
diem nurse who had made the error cornered me in the med room where several
other nurses were working and scolded
me in a loud voice for filling out a variance, saying I was trying to make her
look bad. She told me the whole thing
was not necessary and I was wrong to
have filled out the report. I remember
one nurse quit what she was doing and
left the room.
n I had been on duty for an hour or a bit
longer, when the supervisor entered the
med room where I was. She said to all
staff in the room that she had just received
a call from a patient who was crying. The
patient stated she didn’t know what was
going on with her condition, and her
nurse was nowhere to be found. The
supervisor continued to say it was wrong
not to talk to your patients and who
would be doing this? At that point, I had
“I’ve found that sessions that allow
coworkers to learn about lateral violence
and practice dealing with it together to be
the most effective,” she says.
A community hospital in Rhode Island
holds workshops for nurse managers where
they discuss clinical narratives about lateral
violence incidents that have actually happened to nurses at the hospital (sidebar).
Provide nurses with skills
Nurses need skills to be able to address
conflict with peers, such as conflict management and assertiveness. Bartholomew
said it took about 21⁄2 years of coaching
before she saw a true cultural change on
her unit. But the changes are long lasting
once the staff can recognize lateral violence, see the damage it is causing, and
have the skills to handle it.
not assessed all my patients, so I said it
could be me (I had 6 patients that night).
The supervisor said, “Was a sign for tests
put on the door?” I said, “Yes, I did that
because the secretary asked me to if I was
walking that way, which I was.” I was
scolded in front of everybody. After I got
scolded, the supervisor left and never
asked what I had done toward the
patient’s care, which I thought was
important and substantial.
n I was assigned an admission from the
ER, and I took report from the ER nurse
and admitted the patient. After my initial assessment, I found that the fentanyl patch that was supposed to be on
the patient wasn’t on the patient. I
asked the charge nurse to look with me
but she told me to look again. I did look
again, but no patch. So I asked the
charge nurse a second time to help me
with this, and she told me she guessed if
I wasn’t capable of doing this alone,
she’d have no choice but to see the
patient. Still no patch. As we left the
room, the charge nurse said to figure out
what happened, document it, get another patch from pharmacy, and not bother
her again. I told my manager about the
exchange, and she said there was nothing she could do.
“Nurses need to learn how to go to a
peer and say, ‘I heard you said something
about me,’ or, ‘I was worried when you
rolled your eyes after something I did,’”
she says. “The reality is that we are not
having these crucial conversations and
lack the assertiveness skills to deal with
these conflicts effectively. Learning these
skills is critical to professional relations,
quality of care, and patient safety.”
Give new nurses a shield
Teach newly hired nurses how to shield
themselves from lateral violence. As
Griffin illustrated in her study, coaching
nurses on methods for deflecting lateral
violence, along with cues, can be effective.
Give new nurses a chance to bond
Provide support for orientees to help
keep them from feeling isolated.
“Never hire just one nurse—always
December 2007
Counts off in 1 in 8 general surgery cases
urgical count discrepancies occur
surprisingly often, in about 1 in 8
general surgery cases in a new study.
The counts took an average of 13 minutes
to resolve. In 60% of cases, the discrepancy
was a misplaced item, such as a sponge on
the floor or in the trash.
The study of 148 general surgery cases
is believed to be the first to document surgical count discrepancies based on direct
observation.
In none of the cases was an item left in
a patient’s body.
Counting took an average of 8.6 minutes per case, or about 6% of the operative
time. Discrepancies were most often related to sponges, followed by instruments
and needles. Counts after personnel
changes were more likely to involve a discrepancy than if the original personnel
were present.
“I think people have an idea that these
discrepancies are happening. But I don’t
think anyone would have expected it to be
1 per 8 cases, or 1 per 14 hours of operative
time,” Caprice Greenberg, MD, MPH, a
surgeon and lead author of the study from
Brigham & Women’s Hospital, Boston,
told OR Manager in an interview.
Discrepancies increase the risk of
retained foreign bodies, she says, “because
every time the count is off, we don’t have
an accurate count of what is going on.”
Is technology, such as bar-coded
sponges, the answer?
She and her colleagues have completed
a randomized controlled trial of bar coding technology, being reviewed for publication, which will provide some data. The
new study will also help by providing a
baseline on how counts are performed
currently. The results can be used as a control to see how new technologies perform,
Dr Greenberg says.
“One thing people need to remember
when we think about these new technologies is, while they’re designed to improve
on the current situation, they may or may
not achieve that goal,” she says. “They
might also introduce new system complexities or unintended consequences that
we need to think about.”
hire a minimum of 2,” suggests Bartholomew. “With every nurse you add, you
decrease stress for the group and increase
the chances of them staying.”
Give the group time to share stories
and bond. And keep an eye on what is
happening during the first week and
first month. Keep in touch with new
hires yourself. Have them come by once
a week for a 15-minute chat. Say:
“Come into my office. I want to hear
about your week.”
organization function?’ We all need to
be looking at that.
You really can’t change the people
on the front lines if the leadership does
not support them.” v
—Pat Patterson
S
Offer two-way feedback
Preceptors give feedback to new
nurses every day. Do you also encourage new nurses to give feedback to preceptors?
Bartholomew says one preceptor
was shocked when she heard her orientee say, “I need to know I’m not in your
way, that I am not a bother.” The preceptor didn’t understand why the nurse
felt that way.
“The preceptor ’s body language
conveyed what she was thinking, but
she had no idea she was communicating that,” she notes.
Practice self-evaluation
“To truly embrace change involves
self-evaluation,” Griffin says. “You
need to think about, ‘How does this
December 2007
References
Bartholomew K. Ending Nurse-to-Nurse
Hostility: Why Nurses Eat Their Young and
Each Other. Marblehead, Mass: HCPro,
2006. www.hcpro.com.
Farrell G A. Aggression in clinical settings:
Nurses’ views. J Adv Nurs. 1997;25:501508.
Griffin M. Teaching cognitive rehearsal as a
shield for lateral violence: An intervention for newly licensed nurses. J Contin
Educ Nurs. 2004;35(6):257-163.
Stanley K M, Dulaney P, Martin M M.
Nurses ‘eating our young’—It has a
name: Lateral violence. S Carolina Nurs.
2007;14(1): 17-18.
Stanley K M, Martin M M, Nemeth L S, et al.
Examining lateral violence in the nursing
workforce. Issues Ment Health Nurs. 2007.
In press.
The study is a followup to a 2006
report of observations of 10 complex general surgery cases that found counting to
“significantly compromise” case progress
and patient safety. In that study, 14.5% of
the incision time was spent on counting. In
contrast, the new study, which involved
routine cases, found counting took significantly less time.
The report was presented at the
American College of Surgeons meeting in
October in New Orleans. An abstract is in
the September 2007 Surgical Forum supplement to the Journal of the American
College of Surgeons. v
References
Christian C K, Gustafson M L, Roth E M. A
prospective study of patient safety in the
operating room. Surgery. 2006;139:159173.
Greenberg C C, Diaz-Flores R, Lipsitz S, et al.
A prospective study of the OR counting
protocol. Abstract. J Am Coll Surg.
2007;205(3S):S73.
Most technical errors
involve experienced
surgeons, complex patients
Most technical errors in surgery happen in routine operations with experienced surgeons and involve complex
patients and technology or systems failures, a new study shows.
Examining 258 malpractice claims
involving injuries due to errors, the
researchers found 52% involved technical
errors. The majority of these cases—73%—
involved experienced surgeons, and 84%
happened during routine operations. Twothirds (65%) were linked to manual error, 9%
to judgment, and 26% to both manual and
judgment errors. In all, 61% of the errors
were attributed to patient complexities, such
as emergencies, difficult or unexpected
anatomy, or previous surgery. Technology or
systems failures contributed to 21%.
The authors recommend that surgical
research should focus on improving decision making and performance for routine
operations on complex patients and circumstances. Common interventions such as
having experienced surgeons for complex
procedures and increasing supervision for
trainees will address only a minority of
errors, the authors say. v
—Regenbogen S E, Greenberg C C, Studdert D
M, et al. Ann Surg. 2007:246:705-711l.
11
Managing people
Building enthusiasm
Columbia Hospital
West Palm Beach, Florida
250 beds, 7 ORs
Gary G. Reardon, RN, MSN, MS, CNOR,
director of surgical services
Just 1 year after graduating from nursing school, I became an OR manager. I
took on the responsibility of opening a
new hospital in Canada where I had to
hire and train all the staff. That was where
I developed my orientation program.
Based on that history, it did not bother me
when I came to Columbia Hospital 10
years ago that nurses weren’t coming
through the door prepared for the OR.
I have been meeting with schools in the
area to help them see the importance of
having a perioperative course for nursing
students. I have told them I am willing to
develop an OR program for their students,
such as a 6-week internship.
Here at Columbia, I had to work to
remove the fear that staff and administration had about hiring nurses without OR
experience. I pointed out that I was confident I could train them to become great
OR nurses.
New nurses begin with a general orientation to the hospital and then start the orientation to surgical services. They go over
policies and procedures. They then spend
time in all the departments that report to
surgical sevices and have relationships
with surgical services, such as admitting,
the lab, and sterile processing.
We do it in bite-size pieces. One week
they concentrate only on the admission of
the patient to the preop holding area.
Another week they just focus on preop
preparation and documentation. I want to
make sure they understand the process
their patients go through before they see
them in the OR.
By the end of the first month, they are
rotating through the services with their
preceptors—scrubbing and circulating.
Once they rotate through all of the services, they are placed on call with a backup team member. When called in, they
have the choice to call their backup in or
not. If they feel comfortable doing a case
without a backup person, that’s fine
because I believe it gives them self-confidence and autonomy. The staff also selfschedule.
12
“
The rotation
builds
confidence.
“
If nurses excel in certain cases, we try
to assign them to those cases, but if not,
they understand. Everybody has to be
able to perform any case on call.
We have no vacancies at the present.
We have a high retention rate, with some
staff here for 20 years.
I love what I do, and I like to help get
people enthusiastic about what they’re
learning.
Periop internship pays off
Christiana Care Health System
Wilmington, Delaware
4 surgical sites, 52 ORs
Beth Fitzgerald, RN, MSN, CNOR,
perioperative nurse internship
manager
In response to a growing shortage of
perioperative nurses, Christiana Care
Health System developed a “grow our
own” perioperative internship program in
2000. It was costly but has paid off. Our
internship program has staffed 56% of the
OR positions in 4 facilities in the
Christiana system, and we have an 83%
retention rate for the orientees.
Our 6-month program starts in
September and March, and we offer 6 college credits through Delaware County
Community College. We have taken 2 to 16
interns through the program at one time.
The first 2 weeks begin with classes on
aseptic technique, policies and procedures,
and AORN recommended practices. I
teach scrubbing, gowning, and gloving in
a simulation lab in the shell of two 2 ORs
that were never finished.
After the first 2 weeks, we begin to
practice what has been taught in the lab.
On Mondays and Fridays, we have classroom time to review subjects such as electrosurgery, positioning, or malignant
hyperthermia. On Tuesday, Wednesday,
and Thursday, we move into the clinical
setting and begin scrub rotations. Interns
scrub with a dedicated preceptor in one
service for 4 weeks, then circulate with a
dedicated RN preceptor in the same service for 4 weeks. Every week features a
different competency, such as counting or
specimens. It sounds elementary, but it
works because interns can focus on one
subject at a time.
Following this classroom and clinical
segment, we have a graduation party.
Then the interns enter a 3-week scrub rotation with surgical technologist preceptors
who have been carefully chosen. They
scrub for 3 weeks in one service such as
general surgery or gynecology, and follow
their preceptors’ schedules. Because we
are a trauma center, this schedule allows
the interns to work all shifts and weekends. Then they move into the circulating
role and are with RN preceptors for 3
weeks, again following their preceptors’
schedules.
The rotation builds confidence and
solid knowledge of the services. After this
rotation is completed, they begin another
6-week rotation in another service.
At the end of this 6-month orientation,
the interns leave the internship cost center
and move to the OR site to continue specialty orientations.
After completing the program (from 9
to 11 months, depending on the site), we
ask the new graduates to select a first and
second choice of service to specialize in.
The interns sign a 21⁄2 year contract and
are obligated to pay back $7,500 if they
don’t complete it. With our high retention
rate and having staffed the majority of OR
positions in the system, we think we have
been successful.
Bridge to practice
Northwestern Memorial Hospital
Chicago
744 beds, 52 ORs in 3 pavilions
Christine Bloomfield, RN, MS, CNOR,
program manager for perioperative
education
Northwestern Memorial Hospital and
Northwestern Academy, the teaching arm
of the hospital’s human resources department, have integrated surgical services
with professional education, forming what
we call a “bridge to practice.”
The program, created a year ago, combines the expertise and practical knowledge of the OR educator with the adult
learning theories used by the academy to
December 2007
Managing people
build a new approach for OR orientation.
The program is based on the premise that
an orientation program needs to integrate
practical expertise with adult learning theory and nursing theory.
We start with 6 weeks of AORN’s
Periop 101 curriculum, with a half a day in
the classroom and half a day in the OR.
Two OR educators teach the classes with
me, as well as preceptors.
After this phase, new nurses choose a
service to specialize in and spend 2 weeks
scrubbing and 2 weeks circulating in that
specialty.
We have specialized call teams for each
service, so there is no need for them to
learn all services.
The bridge-to-practice concept combines Periop 101 with kinesthetic learning,
an adult teaching and learning style in
which the student learns by actually carrying out a physical activity. That enables
nurses to apply the principles they learn in
Periop 101.
With this approach, we believe orientees will retain information at a much
higher rate.
Our major focus is on evidence-based
practice. We want nurses to know why
they are practicing a certain way and not
just do things because that is the way it’s
always been done.
Because we just started this program,
we don’t know the effect on retention. One
of my goals is to make our retention rate
our indicator of success.
System effort
Memorial Hermann
Houston, Texas
11-hospital system
Deborah Alpers, RN, administrative
director of perioperative services,
Memorial Hermann Southwest
About 5 years ago, the majority of hospitals in the Houston area had stopped
their training programs for OR nurses. As it
became more difficult to fill vacancies, at
Memorial Hermann Southwest we knew
we needed a breakthrough. I convinced the
administration that my part-time educator
should be made full time, and we launched
an OR internship program.
The program is now part of the
Memorial Hermann system’s educational
and recruitment plan.
Based on AORN’s Periop 101 curriculum, the program consists of 4 weeks of
December 2007
“
What is a
realistic
orientation?
“
classroom instruction followed by 18
weeks of clinical experience in which the
interns rotate through the specialties.
Every other Monday for the 18 weeks, orientees return to the classroom to discuss a
specific specialty and share progress. This
gives them the opportunity to work in a
specialty before hearing the lecture specific
to that specialty. We found this to be more
helpful than including all of the specialty
lectures in the initial 4-week classroom
component.
After the 18 weeks of clinical experience, the interns are working in the ORs
with their preceptors. Usually, within 6
months from the beginning of the program, interns are taking call with a buddy.
The classroom is set up with a mock
OR in a central location. The classes have
had 12 to 16 interns each. The interns sign
a 2-year contract to continue working with
the Memorial Hermann system. So far,
only one nurse has broken the contract
because her husband was transferred. She
did pay the $2,500 fee.
The program is a collaborative effort,
with education staff from multiple facilities
working together to plan and teach the
course. As a result, OR education is now
standardized throughout the system. Hospitals have participated whether they have
a participant in the program or not. The
system effort has been especially valuable
to the smaller hospitals.
Many of us look for nurses within our
own facilities who want the opportunity
to become OR nurses.
Orienting by technology
Massachusetts General Hospital
Boston
900 beds, 42 ORs
Marion Freehan, RN, MPA/HA,
CNOR, nurse director, main ORs
With so much new technology, we had
to look at what would be a realistic orienta-
tion. How much can we teach orientees
and expect them to maintain competency
in? We finally decided to organize orientation around technology rather than service.
We divided the department into 2 parts,
or pods, based on the technology used.
Orthopedic, neuro, plastic, and oral and
maxillofacial surgery are in 1 pod, and all
abdominal and thoracic surgery are in the
other pod. Though there’s huge difference
between a head and a hip, a lot of the same
instrumentation, power equipment, and
technology are used across services such as
neuro- and orthopedic spinal surgery.
New employees are hired for a particular pod and rotate only through services in
that pod. We often have 30 nurses in orientation at one time.
Orientation begins with 1 month of
classroom instruction with observation in
the OR. The orientation is generic at the
beginning. Orientees learn table setups,
draping, and scrubbing, although RNs do
little scrubbing.
After the first month, they begin clinical rotations through the services in their
pod. For the next 8 weeks, they have fulltime preceptors. If all competencies have
been met during this 12- to 13-week phase,
they move into orientation for the entire
pod. The first 2 to 3 weeks of an 8- to 9week service rotation is with a preceptor.
For the remaining time, the orientee transitions to a novice level and is expected to
support staffing numbers independently
on identified novice cases.
When they transition to the next service in the pod, they again have a preceptor for 3 weeks and then become novices
in that service. When orientees have rotated through all services (usually 21 to 24
weeks), they join a “home team” and continue to develop their practice. The total
core education and service orientation
takes 36 to 38 weeks.
The expectation is that they then can
do any case within their pod. Even then,
technology and new procedures present
challenges. It is usually a year before a person is able to take call. But we’re staffed
around the clock, plus we have teams for
night call and weekend call, so they aren’t
called in often.
To me, learning the services has to happen in orientation. If you don’t give nurses
the time they need in orientation, it’s too
hard to play catch-up when you have
them in the staffing numbers and count on
them to staff rooms. v
—Judith M. Mathias, RN, MA
13
Managing people
Which candidates are the keepers?
ow do you know a nurse is a good
fit for the OR—even if the person
doesn’t have OR experience?
There’s a body of research that shows that
the better the fit between an organization
and an employee, the longer the person is
likely to stay.
Managers often say they have a “gut
feeling” about who will make it in the OR.
That’s one piece of the puzzle, but you
need to make sure you have a selection
process that is job related, objective, and
consistent, advises Charles Handler, PhD,
an organizational/industrial psychologist
specializing in employee selection.
You want to ensure every applicant is
evaluated based on the same criteria.
That’s also the best way to ensure the
process can stand up to legal scrutiny, says
Handler, founder of www.rocket-hire.com,
a website that focuses on employee screening and assessment.
Of course, you will review a candidate’s nursing experience and clinical
skills. You will check references to verify
previous employment. But you also want
to know how applicants would handle situations in the OR. Known as “behavioral
interviewing,” this is based on the premise
that the best predictor of future behavior is
how a person responded to similar situations in the past.
Keys to behavioral interviewing:
• Relate the situation directly to the job.
Don’t ask something like, “If you
were an animal, what would you be?”
(OR examples in the sidebar.)
• To help ensure objectivity, rate
responses using a scale planned out in
advance. The scale might outline
behaviors that represent excellent,
average, or poor responses, Handler
suggests.
You might have a committee of managers and staff develop the scenarios and
model responses, with input from the
HR department.
One example of a scenario: “This job
may require you to work overtime on
short notice. How would you handle
that?”
Examples of responses:
• Excellent: “There have been times I
have done this. I have changed my
schedule to meet my work commitment, even though it meant missing a
H
14
Interviewing
scenarios
Two scenarios used by Christiana
Health Care System, Wilmington,
Delaware:
Scenario 1
You are assigned to a trauma case
involving a 15-year-old with multiple lifethreatening injuries from a motor vehicle
accident. The patient is not expected to
survive but is brought to the OR to do
everything that can possibly be done. The
trauma surgeon is visibly upset and has
brought 4 other surgeons with him. This is
going to be a busy case with 5 procedures
taking place at one time (neurosurgery,
orthopedics, general surgery, plastics, and
cardiovascular).
• How will you handle this case emotionally?
• How will teamwork play a role in this
procedure?
Scenario 2
You have been asked to form a team and
revise a policy on retained foreign objects.
Describe how you would facilitate this
teamwork and encourage participation
among the unengaged OR staff.
personal event.”
• Average: “I’d do what I can, but my
own life is important, too.”
• Poor: “This is basically just a job. I
would have trouble making lastminute changes.”
Be sure to train managers and staff
who will be interviewing so they fully
understand the process, Handler adds.
Tips from OR managers
Deborah Alpers, RN, administrative
director of perioperative services at
Memorial Hermann Southwest in
Houston, says she asks a lot of questions
about difficult scenarios.
“If they tend to blame others and don’t
suggest steps they can take to make the
situation better, that turns me off,” she
says. She also finds those who make lists
and take notes during the interview tend
to have good organizational skills, a quality she is looking for.
Beth Fitzgerald, RN, MSN, CNOR,
Interviewing
questions
Some questions asked at Memorial
Hermann Southwest in Houston:
1. Tell us about a time when you were
proud of your decision-making
skills. Pick a problem you have had
to solve, give the details involved in
it, and tell us what you did in creating the solution to that particular
problem.
2. Give a detailed example of what
you do in your current position to
organize yourself to begin your day
and throughout your day.
3. Tell us about a time when you have
had to deal with a person in a position of authority, and you had a difference of opinion. How did you
handle this situation?
4. Tell us about a time when you were
able to achieve something by doing
more than was expected.
5. Describe a situation in which you
were expected to work with an
individual you personally disliked.
What happened?
6. Talk about a time when you made a
personal sacrifice to reach a work
objective.
7. Pick an example from your current
job that would reflect on your ability to deal with pressure and/or
stress.
8. What types of things make you
angry in the work setting?
9. When has a customer or co-worker
been able to make you act less
mature and professional than you
normally do?
perioperative nurse internship manager
for Christiana Care Health System,
Wilmington, Delaware, has applicants
write an essay about why they want to be
an OR nurse.
“For one person, it was because a family member had a good experience with
surgery, and the candidate kept talking
about how wonderful the OR was. For
another, it was the excitement they felt
about wanting to work in surgery. I find
the new graduates especially refreshing
December 2007
Managing people
because they are energetic and excited
about wanting to learn perioperative nursing.” she says.
At Columbia Hospital in West Palm
Beach, Florida, Gary G. Reardon, RN,
MSN, MS, CNOR, says he looks past the
lack of OR experience for something
else—potential and energy.
“My first question is: ‘Why do you
want to be an OR nurse?’” Reardon says.
“If they talk about wanting to get away
from so much shift work, or they have a
babysitter problem, or they really like to
work days, I don’t waste my time.
“But if someone says, ‘I really want to
work in the operating room, if someone
would just give me a chance,’ I keep talking. If I see that desire, I hire them. These
were the characteristics someone saw in
me years ago and gave me a chance.”
Avoiding inappropriate questions
Another benefit of a structured, jobrelated interview is that it helps avoid
improper questions. “Asking inappropriate questions in a job interview is probably
the easiest way to get sued,” Handler says.
Inappropriate questions are those that
place people in a protected class at a disadvantage. Examples of protected classes
are race, ethnicity, religion, national origin,
age, sex, and disability status.
For example, it’s not legal to ask applicants about their plans to bear children,
their date of birth, their marital status, or
whether they own a car unless these questions can be shown to be directly related to
a person’s ability to do a job. v
Incisionless surgery
for acid reflux disease
Surgeons at Ohio State University performed the first incisionless procedures in
the US for gastroesophageal reflux disease,
the university reported in October.
The procedure allows reconstruction of
the valve at the top of the stomach using a
new device introduced through the mouth
and advanced into the stomach. The
EsophyX device by Endogastric Solutions
has been cleared by the Food and Drug
Administration.
Patients are usually in the hospital
overnight and are symptom free, Ohio
State surgeons report. They say the procedure leaves no external scarring, causes little postoperative pain, and reduces recovery time. v
—www.endogastricsolutions.com
December 2007
Patient safety
A time-out tool helps to improve
compliance at the patient’s bedside
he highest priority of any health
care provider is to ensure patient
safety. The single most important
tool for preventing errors is the ability to
communicate. According to the Joint
Commission, the number one cause of
sentinel events is a breakdown in communication among the surgical team,
patient, and family. For wrong surgery,
in 2006, communication was second only
to procedural compliance as a root cause
of these events.
The Joint Commission requires
accredited organizations to adopt the
Universal Protocol for preventing wrong
surgery. The Universal Protocol has 3
major requirements:
• a preoperative verification process
• marking the operative site
• a time-out immediately before the
procedure.
The protocol applies not only for
operative procedures but also for nonOR procedures performed at the bedside. (The only
exception for
bedside procedures is that
the site does
not have to be
marked if the
person
performing the
procedure is
with the patient from the time of the
decision to perform the procedure until
the procedure is performed.)
After reviewing the Joint Commission’s guidelines for the Universal
Protocol and our current policy, we
developed a standardized process to be
used for all surgical procedures that
occur outside the operating room.
In collaboration with our Central
Sterile Processing Department, we identified specific instrument trays that
would be used for bedside procedures.
We attach to the outside of each tray a
time-out document, which serves 2 purposes. The first purpose is to identify the
tray as one that will be used for bedside
procedures requiring a time-out verification. The second purpose is for the document to be used as a written verification
of the procedure, ensuring all necessary
T
To aid site verification for bedside procedures,
a time-out document is attached to each procedure/equipment tray. The wire cart also has
green fluorescent time-out labels.
components of the time-out are included.
In addition to this document, a fluorescent green sticker labeled Time-Out is
visible on the wire cart where the trays
are kept. This green sticker is used by the
nursing units and the Central Sterile
Processing Department. Implementation
of this standardized process has reduced
the incidence of bedside procedure
events related to the Universal Protocol.
—Stephanie Landmesser, RN, MSN,
CNOR
Clinical Nurse Educator of
Perioperative Services
Lankenau Hospital
Wynnewood, Pennsylvania
A copy of the bedside time-out verification
tool is in the OR Manager Toolbox at
www.ormanager.com.
Check our website
for the latest news, meeting
announcements, and other
practical help.
www.ormanager.com
15
OR throughput
Are your operating rooms ‘efficient’?
etting the right case in the right
room at the right time is the goal
for every OR director. Often,
though, defining how well the OR suite
runs depends on whom you ask.
The question, “Are my ORs efficient?” could be could be answered with
a qualitative approach by administering
a written survey to OR personnel. A
more quantitative approach has been
published (Macario, 2006) (see table).
This OR efficiency scoring system could
be used as a management tool. For example, statistical process control techniques
could be used to analyze a dashboard of
these 8 performance indicators to evaluate baseline performance, identify areas
needing improvement, and conduct
prospective monitoring.
Poorly managed OR suites may score
0 to 5 points (on the 0 to 16 scale), while
high scores of 13 to 16 are achievable
with state-of-the-art management systems in place.
The 8 metrics were chosen based on a
review of more than 100 OR management articles published in the literature
in the past decade. These performance
indicators should be able to be computed
from data already available in OR information systems. Surgeon satisfaction is
also critical, but no valid and reliable
instrument to measure this has been
developed.
G
Excess staffing costs due to OR
allocation not being based on
maximizing OR efficiency
Nothing is more important than to first
allocate the right amount of OR time to each
service on each day of the week for its case
scheduling. This is not the same as the
block time! To illustrate, imagine that 2
cases each lasting 2 hours are scheduled
into OR 1 with OR nurses and an anesthesiologist scheduled to work an 8-hour
day. The matching of workload to
staffing has been so poor that little can be
done the day of surgery to increase the
efficiency of use of the staff. Neither
awakening patients more quickly nor
reducing the turnover time, for example,
will compensate for the poor initial
choice of staffing for OR 1 and/or how
the cases were scheduled into OR 1.
Optimal allocation of OR time should
be based on historical use by a particular
16
“
The 8 metrics
are based on
the literature.
“
service (ie, unit of OR allocation such as
surgeon, group, department, or specialty) and then using computer software to
minimize the amount of underutilized
time and the more expensive overutilized time (Strum, et al, 1999).
Underutilized hours reflect how early
the room finishes. In the example above,
if staff were scheduled to work from 7
am to 3 pm, but instead the room finished at 11 am, there would be 4 hours of
underutilized time. The excess staffing
cost (Strum, et al, 1999) would be 50% (4
hrs/8 hrs).
On the other hand, if 9 hours of cases
are performed in an OR with staff scheduled to work 8 hours, then the excess
staffing cost is 25%. Overutilized hours
are the hours that ORs run longer than
the regularly scheduled OR hours, or 1
hour in this example. The calculation is
as follows: 1 hr/8 hr=12.5%, which is
then multiplied by the additional cost of
staying late, which often is assumed to
be a factor of 2 (related to monetary overtime cost paid to staff, as well as recruitment and retention costs related to
unhappy staff because they have to stay
late unpredictably).
OR suites can reasonably aim to
achieve a staffing cost that is within 10%
of optimal (ie, workload is perfectly
matched to staffing).
If the key is to allocate appropriate
time to each service based on historical
OR use, how do you deal with rooms
consistently running late on the day of
surgery? The answer: Make the allocated
time into which cases are being scheduled longer. For example, if a surgeon
does 12 hours worth of cases every day
he is in the OR, don’t plan 8 hours of
staffing (7 am to 3 pm) and have everyone frustrated by having to stay late
(overtime). Rather, schedule his cases
into 12 hours of allocated time (7 am to 7
pm). That way, anesthesia and nursing
staff know they will be there for 12 hours
when they arrive at work, and overtime
costs (financial and morale) will be
reduced. The common response to this
approach is, “No one wants to be there
until 7 pm.” The answer is, “You are
there now until 7 pm, so why not make
the scheduled OR time 12 hours long
and have a more predictable work day
duration?” Thus, optimizing staffing
costs is finding a balance between overtime and finishing early.
There may be concern about the ability to flex staffing enough to avoid excess
staffing costs. It can be difficult to match
scheduled cases with staffing perfectly so
the staff still get the hours and shifts they
need. For example, if Dr Smith needs a
12-hour block, the manager needs to find
staff who want to work a 12-hour shift
(or part-timers in some combination).
Staffing is not only an OR efficiency issue
but also a staff satisfaction issue.
Start-time tardiness
Start-time tardiness is defined as the
mean tardiness of start times for elective
cases per OR per day. Reducing the time
patients have to wait for their surgery
once they arrive at the hospital (especially
if the preceding case runs late) is another
important goal. If a case is supposed to
start at 10 am (patient enters OR), but the
case starts at 10:30 am, there are 30 minutes of tardiness. In computing this metric,
no credit is given if the 10 am case starts
early (for example at 9:45 am).
The tardiness in starting scheduled
cases should total less than 45 minutes
per 8-hour OR day in well-functioning
OR suites. Facilities with long work days
will have greater tardiness because the
longer the day, the more uncertainty
about case start times. Having patients’
medical records ready to go with all
needed documents is essential for ontime starts.
Case cancellation rate on day
of surgery
Cancellation rates vary among facilities, depending partly on the types of
patients receiving care, ranging from
4.6% for outpatients (van Klei, et al,
December 2007
OR throughput
A scoring system for OR efficiency with 8 performance indicators
Metric
Points
0
1
2
>10%
5% -10%
< 5%
> 60 mins
45-60 mins
< 45 mins
Case cancellation rate
> 10%
5% -10%
< 5%
PACU admission delays
(% of workdays with at least one delay of 10 mins
or greater in PACU admission because PACU is full)
> 20%
10%-20%
< 10%
Excess staffing costs
Start-time tardiness
(Mean tardiness of start times for elective
cases per OR per day)
Contribution margin (mean) per OR hr
< $1,000/hr
$1,000/hr-$2,000/hr > $2,000/hr
Turnover times
(Mean setup and cleanup turnover times for all cases)
> 40 mins
25-40 mins
< 25 mins
Prediction bias
(Bias in case duration estimates per 8 hr of OR time)
> 15 mins
5-15 mins
< 5 mins
> 25%
10%-25%
< 10%
Prolonged turnovers
(% of turnovers that are more than 60 mins)
Source: Reprinted with permission from Macario A. Anesthesiology. 2006;1005(2):237-240.
2002) to 13% (Pollard, et al, 1999) to 18%
(Basson, et al) at VA medical centers.
Many cancellations are due to nonmedical problems such as a full ICU, surgeon
unavailability, or bad weather. OR cancellation rates can be monitored statistically (Dexter, Marcon, et al, 2005), and
well-functioning OR suites should have
cancellation rates less than 5%.
Monitoring cancellations correctly is not
taking the ratio of the number of cancellations to the number of scheduled cases
(Dexter, Marcon, et al, 2005).
Postanesthesia care unit
admission
PACU admission delays are defined
as the percentage of work days with at
least one delay of 10 minutes or greater
in PACU admission because the PACU is
full. It is important to adjust PACU nurse
staffing around the times of OR admissions. Algorithms exist that use the number of available nursing hours to find the
staffing solution with the fewest number
of understaffed days (Dexter, Epstein,
2005; Marcon, Dexter, 2006).
Contribution margin per OR hr
An OR suite that puts up with excessive surgical times can schedule itself
December 2007
efficiently but still lose its financial shirt
if many surgeons are slow, use too many
instruments or expensive implants, etc.
These are all measured by the contribution margin per OR hour. The contribution margin per hour of OR time is the
hospital revenue generated by a surgical
case, less all the hospitalization variable
labor and supply costs. Variable costs,
such as implants, vary directly with the
volume of cases performed.
This is because fee-for-service hospitals have a positive contribution margin
for almost all elective cases mostly due to
a large percentage of OR costs being
fixed. For US hospitals not on a fixed
annual budget, contribution margin per
OR hour averages $1,000 to $2,000 US
per OR hour (Dexter, Ledolter et al, 2005;
Dexter, Blake, et al, 2002; Macario,
Dexter, et al, 2001).
Turnover times
Turnover time is the time from when
one patient exits an OR until the next
patient enters the same OR (Donham, et
al, 1999). Turnover times include cleanup
times and setup times but not delays
between cases. Based on data collected at
31 US hospitals, turnover times at the
best performing OR suites average less
than 25 minutes (Dexter, Epstein, et al,
2005). Cost reduction from reducing
turnover times (because OR workload is
less) can only be achieved if OR allocations and staffing are reduced (Dexter,
Abouleish, et al, 2003). Despite this,
turnover time receives lots of attention
from OR managers because it is a key
satisfier for surgeons.
Sometimes an OR suite reduces
turnover times (by providing more staff
to clean the room, for example), but new
problems arise (such as not enough time
for sterilizing instruments for the new
case or not being able to take the patient
to the PACU because there are no beds)
that were “hidden” by long turnover
times.
Times between cases that are longer
than a defined interval (eg, 1 hour
because the to-follow surgeon is unavailable) should be considered delays, not
turnovers (Dexter, Macario, et al, 1999).
Prediction bias
Prediction bias is defined as bias in
case duration estimates per 8 hours of
OR time. Prediction error equals the
17
OR throughput
actual duration of the new case minus
the estimated duration of the new case.
Bias indicates whether the estimate is
consistently too high or consistently too
low, and precision reflects the magnitudes of the errors of the estimates.
Efficient OR suites should aim to have a
prediction bias that is less than 15 minutes (Dexter, Macario, et al, 2005). A reason for bias can be surgeons consistently
shortening their case duration estimates
because they have too little OR time allocated and need to “fit” their list of cases
into the OR time they do have. In contrast, surgeons may purposely overestimate case durations to keep control of or
access to their allocated OR time so if a
new case appears, their OR time is not
given away.
Remember that lack of historical case
duration data for scheduled procedures
is an important cause of inaccuracy in
predicting case durations. In general,
half of the cases scheduled in your OR
suite tomorrow will have less than 5 previous cases of the same procedure type
and same surgeon during the preceding
year (Zhou, et al, 1999).
It would be nice to have no uncertainty in case duration prediction. But it is
present. The problem is looking for a single number that is correct most of the
time. You won’t get accurate estimates by
using historical case duration data.
Rather, from the historical data, you’ll
get an assessment of the uncertainty.
With proper management weeks to
months ahead of time, the groundwork
for an efficient (well-functioning) OR
suite should be in place. Statistical
process control could be used to prospectively monitor a dashboard of items,
such as the ones discussed above. v
—Alex Macario, MD, MBA
Department of Anesthesia
Stanford University School of
Medicine
Summarized with permission from Macario,
A. Are your hospital operating rooms “efficient”? Anesthesiology. 2006;105:257-260.
References
Abouleish A E, Dexter F, Epstein R H, et
al. Labor costs incurred by anesthesiology groups because of operating
rooms not being allocated and cases
not being scheduled to maximize oper-
18
ating room efficiency. Anesth Analg.
2003;96:1109-1113.
Basson M D, Butler T W, Verma H.
Predicting patient nonappearance for
surgery as a scheduling strategy to
optimize operating room utilization in
a veterans’ administration hospital.
Anesthesiology. 2006;104(4):826-834.
Dexter F, Abouleish A E, Epstein R H, et
al. Use of operating room information
system data to predict the impact of
reducing turnover times on staffing
costs. Anesth Analg. 2003;97:1119-1126.
Dexter F, Blake J T, Penning D H, et al.
Calculating a potential increase in hospital margin for elective surgery by
changing operating room time allocations or increasing nursing staffing to
permit completion of more cases: A
case study. Anesth Analg. 2002;94:
138–142.
Dexter F, Epstein R H, de Matta R, et al.
Strategies to reduce delays in admission into a postanesthesia care unit
from operating rooms. J PeriAnesth
Nurs. 2005;20:92-102.
Dexter F, Epstein R H, Marcon E, et al.
Estimating the incidence of prolonged
turnover times and delays by time of
day. Anesthesiology. 2005;102:1242-1248.
Dexter F, Ledolter J, Wachtel R E. Tactical
decision making for selective expansion of operating room resources
incorporating financial criteria and
uncertainty in sub-specialties’ future
workloads. Anesth Analg. 2005;100:
1425-1432.
Dexter F, Macario A, Epstein R H, et al.
Validity and usefulness of a method to
monitor surgical services’ average bias
in scheduled case durations. Can J
Anesth. 2005;52:935-939.
Dexter F, Macario A, Qian F, et al.
Forecasting surgical groups’ total
hours of elective cases for allocation of
block time. Anesthesiology. 1999;91:
1501-1508.
Dexter F, Marcon E, Epstein R H, et al.
Validation of statistical methods to
compare cancellation rates on the day
of surgery. Anesth Analg. 2005;101(2):
465-473.
Donham R T, Mazzei W J, Jones R L, et al.
Procedural times glossary. Am J
Anesthesiology. 1999;23,5 Suppl:4.
Macario A. Are your hospital operating
rooms “efficient”? A scoring system
with eight performance indicators.
Anesthesiology. 2006;105(2):237-240.
Macario A, Dexter F, Traub R D. Hospital
profitability per hour of operating
room time can vary among surgeons.
Anesth Analg. 2001;93:669–675.
Marcon E, Dexter F. Impact of surgical
sequencing on post anesthesia care
unit staffing. Health Care Manag Sci.
2006; 9:81-92.
Pollard J B, Olson L. Early outpatient preoperative anesthesia assessment: Does
it help to reduce operating room cancellations? Anesth Analg. 1999;89:
502–505.
Strum D P, Vargas L G, May J H. Surgical
subspecialty block utilization and
capacity planning: A minimal cost
analysis model. Anesthesiology.
1999;90:1176-1185.
van Klei W A, Moons K G, Rutten C L, et
al. The effect of outpatient preoperative evaluation of hospital inpatients
on cancellation of surgery and length
of hospital stay. Anesth Analg. 2002;94:
644–649.
Zhou J, Dexter F, Macario A, et al. Relying
solely on historical surgical times to
estimate accurately future surgical
times is unlikely to reduce the average
length of time cases finish late. J Clin
Anesth. 1999;11:601-605.
Elective ORs better for
emergencies in study
Emergency patients were operated on
more efficiently by reserving capacity in
elective ORs rather than having dedicated emergency ORs, in a new study from
The Netherlands.
The study used a simulation model to
examine the 2 approaches to reserving
capacity for emergencies. The outcome
measures were waiting time, staff overtime, and OR utilization.
Results indicated that the policy of
reserving emergency capacity in all elective ORs led to improved waiting times
for emergency surgery from 74 minutes
to 8 minutes. Overtime was reduced by
20%, and overall utilization increased by
about 3%.
The results led to the closing of the
emergency OR at the Erasmus University
Medical Center in Rotterdam. v
—Wullink G, Van Houdenhoven M,
Hans E W, et al. J Med Syst. 2007;
31:543-546.
December 2007
OR Business
Management
Conference
May 19-21, 2008
Hyatt Regency
San Francisco
at the Embarcadero Center
20
MATROX GRAPHICS INC.
Managing Today’s OR Suite
Managing people a theme at conference
he power of teams and a culture of
collaboration were themes at the
Managing Today’s OR Suite conference Oct 3 to 5 in San Diego. The conference attracted 726 attendees for the 2-day
conference and 390 for the preconference
seminars. They visited an exhibit featuring
88 companies.
Attendees gave the conference high
ratings, with 92% rating it as “excellent” or
“very good” and 100% saying they
thought the content would be valuable in
their work settings.
Barbara Johnson, RN, BSN, MHA, was
honored as OR Manager of the Year.
Johnson, director of perioperative nursing
at Piedmont Hospital in Atlanta, said she
has “the best perioperative team in the
universe.” She advised managers, “Don’t
think you have to have all the answers—
rely on your staff.”
T
Select for talent
How do you build great teams?
One answer is to select people who
have the right talent, said Curt Coffman in
his keynote, sponsored by Kimberly-Clark
Health Care. Coffman told of a man who
asked a circus performer how he trained
his dogs to do amazing tricks. The reply:
“I find the ones who can do it, and I pick
them.”
”It’s more effective to find the role that
fits the person than try to rewire someone
to fit the role,” he said. “If you can find
someone and reposition them, they can
become a great performer.”
Coffman is coauthor with Marcus
Buckingham of the best seller, First, Break
All the Rules: What the World’s Greatest
Managers Do Differently (Simon & Schuster, 1999).
Match peoples’ talents to their roles,
keynoter Curt Coffman advised.
to move them to do what needs to be done.
“They are very clear about what is
important to them. And they understand
themselves well enough to talk, walk, and
live what is important to them.”
After McKee’s lecture, the audience
gathered poolside for a gala wine-tasting
reception sponsored by Integrated
Medical Systems International, Inc.
“People will walk through a wall for you
if they believe you care about them,”
said Annie McKee, PhD.
Failure is not final
The message from CDR Scott Waddle,
USN (Ret), about his recovery from a devastating error in which the submarine he
commanded caused the death of 9 people,
struck a cord with the audience during a
session sponsored by the J2 Group, Inc,
Perioperative Health Systems Consulting.
Waddle, who had had a stellar career
Becoming a resonant leader
Great leaders like Nelson Mandela
have high emotional intelligence—the
ability to manage their emotions and
inner potential for positive relationships, said Annie McKee, PhD, who
spoke at a special lecture sponsored by
Cardinal Health, Medical Products and
Services. McKee is author with Richard
Boyatis of Resonant Leadership, which
builds on their work with Daniel
Goleman on emotional intelligence.
Such leaders, she said, “know how to
manage emotion in themselves and others
December 2007
Barbara Johnson,
RN, BSN, MHA,
of Atlanta,
OR Manager of the
Year (right),
receives her plaque
from OR Manager
President Ellie
Schrader.
21
Attendees sampled
California wines at a
poolside reception
sponsored by IMS.
Creating a just culture
A just culture creates a fair and open
atmosphere, David Marx explained.
with the Navy, commanded the nuclear
submarine USS Greeneville. On Feb 9,
2001, during a visit to the submarine by a
group of civilians, he ordered a maneuver
that caused the submarine to rise to the
surface in seconds, crashing into a
Japanese fishing trawler, thought to be
miles away. The trawler sank in less than 3
minutes, killing 9 people, including 4 17year-old students.
Waddle emotionally described his devastation. “How did we miss this?” he kept
asking himself right after the crash. After
being relieved of command, he told his
crew to tell the truth. Waddle spiraled into
deep despair, even briefly thinking about
taking the lives of his family and himself.
But he turned to his long-held tenets:
integrity, accountability, and responsibility.
At the court of inquiry, Waddle told the
truth and took responsibility for the incident. He testified and sent letters of apology to the families, whom he was not
allowed to meet. He was allowed to retire
and retain his pension.
He finally wrote a book, The Right
Thing, and in 2002, was able to travel to
Japan to apologize in person.
He encouraged the audience, which
responded with a standing ovation, to
think about what they would do if tested
by something like a sentinel event, advising, “Keep your character and integrity
intact.”
22
How can you hold people accountable
without finger pointing? One answer is
the Just Culture Model.
David Marx, JD, president of Outcome
Engineering, LLC, Plano, Texas, who
developed the model, explained that just
culture falls in the middle of the continuum from a blame-free culture to a punitive
culture.
“We are fallible creatures,” Marx said.
“Rules that say we can’t make mistakes
will fail.” Instead, a just culture balances 3
duties—avoid causing unjustified risk or
harm, produce an outcome, and follow a
procedural rule—with organizational and
individual values such as safety, cost effectiveness, equity, and dignity.
Creating a just culture takes time, he
said, because managers’ and staffs’ expectations must change. Managers must
understand risk, design safe systems, and
facilitate safe choices by staff. The staff
should be expected to look for risks, report
errors and hazards, help design safe systems, and make safe choices. The staff
needs to learn to ask, “What is the risk not
worth taking?” which Marx said is the
most important question.
A carrot a day keeps your staff
Closing the conference was Max
Brown, of the Carrot Culture Group, a
division of OC Tanner Company, which
Oct 29-31, 2008
Gaylord National
Washington, DC, metropolitan area
A brochure will be posted in March
at www.ormanager.com and
included in the April OR Manager.
Elvis returned to sing at
the IMS reception.
produced the best seller The Carrot
Principle, a book based on the simple concept that recognizing employees generates
commitment and leads to high-level performance. The luncheon was sponsored
by Advanced Sterilization Products.
Conveying his message with humor,
Brown had volunteers toss stuffed carrots
into the audience to make his point that
recognition is what keeps top employees—“88% cite lack of recognition as the
number 1 reason they leave,” he said.
For recognition to be authentic and
successful, Brown said it must be frequent,
timely, and specific. v
December 2007
CMS sets final 2008 ASC payment rates
or 2008, ambulatory surgery centers
(ASCs) generally will be paid at 65%
of hospital outpatient department
(HOPD) payments, under a final rule
issued Nov 1 by the Centers for Medicare
and Medicaid Services (CMS). The rule,
effective Jan 1, 2008, sets rates for the first
year of the new ASC payment system, the
most significant change in Medicare ASC
reimbursement in 20 years.
The same rule updates the hospital
outpatient payment system, resulting in
an average overall outpatient payment
increase of 3.8%. From now on, ASC payments will be updated jointly with the
hospital outpatient payments.
The new rule does not make changes
in the ASC payment system itself; those
rules were final in August.
The new payment system patterns
ASC payments after the hospital outpatient system. As such, ASCs will be paid
according to rates set for APCs (ambulatory payment classifications) rather than
the groupers ASCs are used to. But CMS
will report payment rates by CPT code
so ASCs will not need to determine
which APC a CPT code belongs to, FASA
notes in an overview of the rule on its
website (www.fasa.org).
The Nov 1 rule also finalizes at 3,390
the list of procedures payable in the ASC
setting in 2008, which is 819 more than
the current list.
F
“
Medicare will
pay for lap
chole in ASCs.
“
As part of the new payment system,
CMS adopted a new policy that will
allow ASC payments for any procedure
not specifically excluded from the list.
Excluded procedures, in general, are
those that are on the CMS inpatient list,
typically require active medical monitoring and care after midnight on the day of
the procedure, or are deemed to pose a
safety risk for Medicare patients in ASCs.
Under the new policy, Medicare will
now pay for laparoscopic cholecystectomy in ASCs. FASA argues that lap chole
should have been included on the list
even under the old system.
In response to public comments questioning the safety of some procedures in
ASCs, such as balloon angioplasty of the
peripheral vessels, CMS says its medical
experts did a comprehensive review. As
a result, CMS decided to leave on the
ASC list iliac and venous angioplasty
(CPT 35473 and 35476) but to exclude
femoral-popliteal angioplasty (CPT
35474) for safety reasons.
A list of the excluded procedures is at
www.cms.hhs.gov/ASCPayment. On
the left, look for CMS-1392-FC. Scroll
down to Appendix EE.
Four-year phase-in
Payment rates under the new ASC
system will be phased in over 4 years for
procedures currently on the ASC list, giving ASCs time to adjust. Procedures
added to the list will transition immediately to full payments under the new
system.
FASA said it would post on its web
site the national 2008 ASC payments plus
what rates would be if the rates were
fully adopted in 2008. FASA will also
post a rate calculator ASCs can use to
determine what their local payments will
be.
Why will ASCs be paid 65%?
CMS says the 65% amount was set to
keep the ASC payment system budget
neutral. FASA explains how this was
determined: CMS sets payments for each
APC based on the APC’s relative weight,
a measure CMS uses to rank the costs of
performing procedures in one APC compared with the costs of other APCs, plus
a uniform conversion factor that applies
Ambulatory Surgery Advisory Board
Lee Anne Blackwell, RN, BSN, EMBA, CNOR
National director, clinical education,
ambulatory surgery division, HealthSouth
Corporation, Birmingham, Alabama
Rebecca Craig, RN, BA, CNOR, CASC
Administrator, Harmony Ambulatory
Surgery Center, LLC, Fort Collins,
Colorado
Nancy Burden, RN, MS, CAPA, CPAN
Director, Ambulatory Surgery, BayCare
Health System, Clearwater, Florida
Stephanie Ellis, RN, CPC
Ellis Medical Consulting, Inc
Brentwood, Tennessee
Lisa Cooper, RN, BSN, BA, CNOR
Executive director, El Camino Surgery
Center, Mountain View, California
Ann Geier, RN, MS, CNOR, CASC
Vice president of operations
Ambulatory Surgery Centers of America
Norwell, Massachusetts
December 2007
Rosemary Lambie, RN, MEd, CNOR
Nurse administrator, SurgiCenter of
Baltimore, Owings Mills, Maryland
LeeAnn Puckett
Materials manager, Evansville Surgery
Center, Evansville, Indiana
Donna DeFazio Quinn, RN, BSN, MBA,
CPAN, CAPA
Director, Orthopaedic Surgery Center
Concord, New Hampshire
23
Ambulatory
Surgery Centers
Bill seeks higher
pay rate for
ambulatory surgery
centers
A new bill (S 2250) introduced by
Sen Mike Crapo (R-ID) on Oct 26 seeks
to improve the reimbursement system
for ambulatory surgery centers. The
bill, a companion to House Bill 1823,
would continue to link ASC payments
to the hospital outpatient rate, as in the
current CMS rule. But the bill seeks to
set ASC payments at 75% of what hospital outpatient departments receive
rather than the 65% provided for ASCs
in 2008.
Sen Crapo said the bill would allow
ASCs to provide more services, encourage competition, and generate savings
for Medicare and its beneficiaries.
For more, visit the FASA website at
www.fasa.org.
to all APCs. The relative weights for each
APC are determined using hospital cost
reports. The relative weight is then multiplied by a uniform dollar conversion
factor to get the national HOPD rate.
In 2008, the relative weights for calculating ASC payments for each APC will
be the same as the relative weights used
for HOPDs. The process for calculating
the payment rates will also be the same,
except different conversion factors will
be used for ASCs and HOPDs. In 2008,
the ASC conversion factor will be 65% of
the hospital conversion factor. Local
adjustments are also applied.
This is the percentage CMS believes is
budget neutral, meaning that even if the
new ASC payment system was not
implemented for 2008, CMS figures the
overall ASC payment rates would still
total 65% of the HOPD rates.
Because of differences in the annual
updates, ASCs believe payments
between surgery centers and HOPDs
will continue to diverge over time. The
ASC community is seeking legislation to
remedy that. A Senate bill was introduced in October that would set ASC
24
“
New bill
seeks to set ASC
pay at 75%.
“
payments at 75% of HOPD payments.
ASCs maintain this would allow them to
provide more services at a lower cost to
Medicare patients than what hospitals
provide.
Procedures not paid at 65%
There are some procedures that will
not be paid at 65% of the HOPD rate,
FASA notes. These include the following:
Device-intensive procedures
ASCs will be paid more for procedures that require use of a device that
costs more than 50% of the total APC
reimbursement. For these, ASCs will be
paid the same as HOPDs for the device,
with the 65% discount for ASCs applied
to the rest of the APC reimbursement. In
all, 45 procedures are designated as
device intensive for 2008. Examples are
insertion of pacemakers, pulse generators, and pacing or defibrillator leads;
insertion of male slings; cryoablation of
the prostate; implant of spinal infusion
pumps; and implant of cochlear devices.
Some commenters asked CMS to
include other procedures with expensive
implants in this category. One is injecting
implant material into urethral or bladder
tissues for incontinence (CPT 51715). But
CMS declined, saying its payment policy
is final for 2008.
Procedures frequently performed
in physician offices
ASC payments for 365 procedures
performed more than 50% of the time in
physician offices will be less than 65% of
HOPD payments. For those, CMS limits
payment to the lesser of the payment
rate determined using the 65% methodology or to the cost of the physician’s
practice expense when performed in the
Key facts on ASC
2008 payment rule
• For 2008, ASCs will generally be
paid 65% of hospital outpatient
department (HOPD) payments.
• A total of 3,390 procedures will be
payable in the ASC setting in 2008,
up by 819 from the current list.
• There is a 4-year phase-in to the
new payment system for procedures currently on the ASC list.
• New procedures added to the list
will be paid under the new payment system immediately.
• Some procedures are not affected by
the 65% ASC discount: from HOPD
payments:
—Procedures requiring a device
that costs more than 50% of total
APC reimbursement.
—Procedures frequently performed
in physician offices, for which the
ASC payment will be the lesser of
the payment rate determined using
the 65% methodology or the cost of
the physician's office expense for
the procedure when performed in
the office.
Sources: Centers for Medicare and
Medicaid Services, FASA.
office. CMS set these limits to discourage
procedures performed most of the time
in the less expensive office setting from
migrating to the ASC. v
FASA and AAASC have information and
tools for gauging the impact of the new payments on your ASC at www.fasa.org and
www.aaasc.org.
The final payment update rule is at
www.cms.hhs.gov/ASCPayment. The rule
was scheduled to appear in the Nov 27
Federal Register, which will be posted at
www.gpoaccess.gov/fr.
December 2007
Ambulatory
Surgery Centers
Tips for a successful hire in your ASC
he temporary staffing agency you
use for your ASC assures you it conducts thorough background checks.
You decide to hire the accounts receivable
clerk sent from the agency. Your prehire
background check reveals the clerk spent
time in prison for embezzlement. You
escort the clerk out the door.
Most managers have some kind of horror story about a seemingly good hire
gone bad. Hiring in an ASC is often challenging. The ASC administrator may double as the human resource (HR) manager,
or the HR resource may be off-site and not
readily available.
“You don’t necessarily have a lot of
backup,” says Lisa Cooper, RN, BSN,
CNOR, chief executive officer of El
Camino Surgery Center in Mountain
View, California. How can you enhance
your chances of making a smart hire?
Heed this advice from the experts.
T
Common mistakes
The most common mistake managers
make is talking first and too much, says
Susie Hardin, vice president of human
resources for Symbion in Nashville,
Tennessee. “People explain the company
and job up front, then ask the candidate
about themselves, but you’ve already
given them the answers. It’s better to let
the candidate speak first.”
Another common mistake is basing a
decision to hire on a person’s credentials
or past jobs, assuming he or she will know
the clinical procedures performed in the
ASC. Hardin suggests asking candidates
to explain the steps of a procedure rather
than asking for a yes or no as to whether
they know how to do it.
Ann Bures, RN, MA, CHCR, past president of the National Association of Health
Care Recruiters (NAHCR), reminds managers they need to understand their work
environment and work group dynamics.
“What kind of person will fit with the
group? If you have an assertive group, can
a candidate stand up to that?” Bures suggests asking the candidate, “How do you
introduce yourself to a new work group?”
and “Describe a time when you encoun-
December 2007
tered a difficult situation with a coworker.”
Honesty is a 2-way street between the
manager and the candidate.
“Be clear about the negatives, too,
because every place has good and bad,”
says Cooper. “If there will be a lot of overtime, don’t hide it; be upfront about it.”
Otherwise, the staff member may leave,
putting you back where you started.
Overlooked but vital
“I’ve seen it over and over again,” says
Hardin. “Hiring managers don’t check references. So many problems could have
been prevented if only a thorough reference check was done.”
Hardin recommends using only supervisors, not coworkers, for references and
remembering that if the candidate gives
you the name, chances are the reference
will be positive. She calls the candidate’s
immediate supervisor first because he or
she will frequently provide more information than the human resources department, which often gives only dates of
employment.
Even limited information can be helpful, particularly when evaluating the
length of employment listed on the
resume, especially for those candidates
who list only years. For example, a nurse
lists her tenure at a previous job as 20052007, implying she was employed for 2
years. However, further research reveals
she started in December 2005 and left in
January 2007, closer to 1 year and half the
experience, a significant difference.
Cooper is particularly interested in the
tenure of candidates for jobs in lower
salary brackets. “Those positions are a little easier to fill, so if they are moving
around, it likely means they are job hopping.”
With these candidates, Cooper also
focuses more on the details of getting to
work on time because people with lower
incomes often have fewer resources to fall
back on.
Screening for secrets
Criminal background checks and drug
screens have become routine in job hiring.
An offer of employment is made contingent on the results of screening, background checks, and reference checks.
It’s not unusual for these checks to
come back positive. Hardin estimates that
about 25% reveal misdemeanors such as
possession of marijuana, writing bad
checks, reckless driving, driving without a
license, and driving under the influence
(DUI) without injury to another person.
Felonies such as rape or burglary are “few
and far between.”
Cooper counsels manager to be careful
when hiring a company to conduct background checks. She recommends contacting local hospitals and major businesses to
obtain recommendations. “I would not
just look on the Internet,” she says. Cooper
adds that managers should also evaluate
the company a staffing agency uses for
checks to ensure it’s doing a good job.
How does a history of drug use or a
criminal record factor into the hiring decision? Hardin recommends considering if it
was a misdemeanor, how long ago it
occurred, how old the person was at the
time of the infraction, and whether it was
an isolated incident or part of a pattern.
“Consistency is very important, in case
you are ever challenged in court.”
Another factor is how forthcoming the
candidate is. During the interview Cooper
likes to ask, “We run an extensive background check. Is there anything you’d like
to tell me before we do that?”
“If they don’t say anything, and something comes up on the check, that’s probably reason enough not to hire them,” she
says.
Take time now, not later
Making the right hire takes time. It’s
not easy being patient when you’re faced
with open positions.
“People get desperate,” says Cooper,
“they make a quick decision and don’t
wait until the fit is right.” But not taking
time during the hiring process can cause
problems down the road and more time
on the manager’s part.
To avoid the hasty hire, “managers
25
Ambulatory
Surgery Centers
must be prepared,” says Bures. She recommends a structured approach, including
reviewing the application, having a set of
probing questions, and using a questionnaire related to ambulatory surgery.
Bures uses the Healthcare Selection
Inventory (HSI) from TestSource, a company in Grand Rapids, Michigan, that specializes in assessment and retention in health
care (http://testsource.com). The HSI
Feedback Report provides an overview of
the candidate’s potential for success on the
job and includes three scales: Overall
Performance Index, Retention Index, and
Service Excellence Index. The tool takes a
candidate about 20 to 30 minutes to complete and can be done before the interview.
Similar tools are available from other companies.
Bures credits the inventory, face-toface interview, and time in the OR
shadowing another employee as a combination that’s worked well for her. She
prepares the staff with questions they
can ask the candidate during the shadowing experience. Shadowing helps
ensure a good fit and gives peers a
chance to ask questions.
Partnership and processes
Bures recommends working closely
with your HR contact to ensure an efficient, effective interview process. That
will help save time and lessen the
chances of making a poor decision.
After employees have been on the
job for about a month, Hardin likes to
ask them if the job turned out to be
what they expected and if it matched
with what they heard in the interview.
That step will help fine-tune your hiring process.
You have to be an investigator, a critical thinker, and a good listener to
match the right person to the right job.
It can be a challenge, but the reward is a
satisfied, long-term employee. v
—Cynthia Saver, RN, MS
Cynthia Saver is a freelance writer in
Columbia, Maryland.
26
More questions to hire by
Most of these interview questions
fall into “behavioral interviewing,” a
technique predicated on the idea that a
person’s past performance indicates
future performance. It emphasizes
questions that elicit descriptions of specific behaviors in response to various
situations.
1. What do you want from a job and a
company?
2. Why did you leave your previous
position?
Susie Hardin of Symbion, Nashville,
Tennessee, says to match the answer
against the resume. “If they say it
was for more money, but there’s a
gap in employment, they didn’t
leave for more money.”
3. Tell me about a time you had a
physician throw an instrument or
engage in another act of conflict.
“You need to ask about how they
handle nurse-surgeon friction,” says
Ann Bures, RN, MA, CHCR, past
president of the National
Association of Health Care
Recruiters.
4. Describe your personality to me.
“Usually they’ll say they are a ‘people person,’” says Hardin. “But I’ve
had people tell me they were selfish,
opinionated, or self-centered.” She
recommends doing this before you
share what kind of employee you
are seeking.
5. What would your current manager
say about you? How would he or
she describe you as far as your
work ethic and reliability?
6. Describe some of the typical aspects
of your day.
“This tells you about their abilities
to set priorities and delegate,” says
Bures.
Surgeon faulted in wrong-site case
neurosurgeon, J. Frederick Harrington, MD, bears most of the
blame for operating on the wrong
side of the patient’s head in July at
Rhode Island Hospital, the state’s health
department concluded in October, the
Providence Journal reported.
A
The surgeon was allowed to resume
surgery in October without restrictions.
He stopped operating voluntarily shortly after the error.
Though wrong-site operations often
involve a cascade of errors, in this case,
most of the blame lies with the surgeon,
said Robert S. Crausman, MD, head of
the state’s medical board.
The case involved an 86-year-old
man with a subdural hematoma who
was admitted through the emergency
department and had the wrong side of
his head treated. When the error was
discovered, treatment was performed
successfully on the correct side. The
patient later died. Results of the investigation into the cause of death had not
been reported at press time.
The state found Dr Harrington failed
to check the CT scan images of the
brain but relied on his memory and
failed to pause before the procedure
began when someone in the OR questioned him.
The state said systems issues at the
hospital contributed to the error. The
hospital has been studying the issues
and making changes to prevent similar
events in the future, an administrator
from the hospital’s parent company
told the Journal. Among these are new
procedures for emergency cases.
Access the article on the Journal website at www.projo.com. Enter search
term “Frederick Harrington.” v
December 2007
OR Manager Subject Index 2007
VOLUME 23
— Index by Mary Walsh, MLS
ACCREDITATION
Bariatric accreditation options, Jan: 14
Ready for bariatric surgery?, Apr: 23
AMBULATORY SURGERY
2007 ASC Salary/Career Survey, Oct: 27
2007 ASC Salary/Career Survey, Sep: 12
AAASC and FASA to merge, Nov: 28
Advanced spine surgery center, Nov: 29
ASC financial benchmarking, Jan: 26
ASC focuses on savings, Aug: 29
ASC payment rates, 2008: Dec: 23
ASC pay plan still falls short, Sep: 25
ASC salary/compensation, Oct: 29
ASC Supply cost data stories, Jun: 27
CMS ASC payment overhaul coming,
Jul: 25
CMS updates ASC coverage rule, Oct: 32
GOA agrees on ASC pay, Jan: 30
Hiring tips for ASCs, Dec: 25
Improving ASC revenue, part 1, Apr: 28
Improving ASC revenue, part 2, May: 27
Patient discharge: quick and safe, Mar: 23
Plan an ASC open house, Jul: 29
Plans reward peak performers, Feb: 23
Preventing TASS: expert advice, Aug: 25
Risk management vulnerability, Feb: 27
Spine surgery in the ASC, Nov: 25
Stronger supply chain: 7-steps, May: 25
AORN
Weight of instrument sets, May: 5
BARIATRIC SURGERY
Bariatric accreditation options, Jan: 14
Becoming a bariatric center of excellence,
Jan: 1
BENCHMARKING
ASC financial benchmarking, Jan: 26
GI endoscope benchmarking, Nov: 19
BUSINESS
‘Diamond standard’ for supply chain,
Jul: 20
Editorial, Aug: 3
Get more from value analysis, Jun: 18
Improving ASC revenue, part 1, Apr: 28
Improving ASC revenue, part 2, May: 27
OR analyst: support periop leaders,
Aug: 17
OR business manager roles, Aug: 19
Physician conflicts of interest, May: 1
Physician-led value analysis, Jun: 16
Plan an ASC open house, Jul: 29
Warranty for CABG?, Aug: 1
CHANGE
Atul Gawande on safer surgery, May: 9
Manage with positive redirection, Jun: 23
CMS (CENTER FOR MEDICARE &
MEDICAID SERVICES)
ASC payment rates, 2008: Dec: 23
ASCs lobby on pay plan, Apr: 21
December 2007
Jul: 25
CMS guideline changes, Jan: 1
CMS revises rules, Jan: 9
CMS updates ASC coverage rule, Oct: 32
Informed consent guidelines revised,
Jun: 5
Outpatient quality reporting slated, Sep: 5
Some errors no longer paid for, Oct: 5
CODING
Jul: 25
COMMUNICATION
Accurate surgeon preference lists, Nov: 1
JCAHO Hot Spot, Jan: 21
Lateral violence, Dec: 1
Lateral violence & managers, Dec: 10
Make the break from 5x7 cards, Nov: 9
Military team training (TeamSTEPPS),
Jun: 22
Postop debriefing for early-warning,
Jul: 10
Preop briefings boost safety, Jul: 1
Preop briefings for patient safety, Mar: 1
Support for when things go wrong, Jul: 17
Timeout: it’s apple pie, Jul: 14
COMPETENCE
Competencies for OR management, Jun: 9
Retained objects reduction, Apr: 8
CONFLICT RESOLUTION
Lateral violence, Dec 1
CONSENT – SEE INFORMED CONSENT
COSTS & COST CONTROLS
ASC supply cost data stories, Jun: 27
Implant costs sway MDs, May: 21
Questions re: ortho navigation, Sep: 1
DESIGN & CONSTRUCTION
OR construction track, Feb: 7
DEVICES - SEE SUPPLIES & EQUIPMENT
DISASTER PLANNING
Disaster preparedness checklist, Aug: 12
Planning for the worst, Aug: 1
DISCHARGE PLANNING
Minimizing discharge risks, Mar: 27
Patient discharge: quick and safe, Mar: 23
Revised PADSS, Mar: 25
DOCUMENTATION
Good data to guide decisions, Sep: 19
Moving to online charting, Apr: 11
EDUCATION
Jun: 22
Simulation labs aid staff education, Jan: 16
EFFICIENCY - SEE PRODUCTIVITY
EMPLOYMENT
2007 Salary/Career Survey, Sep: 1
Hiring tips for ASCs, Dec: 25
Interviewing candidates, Dec: 14
National shortage snapshot, Sep: 14
Opportunities in interim management,
Apr: 1
Orientation trends, Dec: 1
ERRORS - SEE TREATMENT ERRORS
ETHICS
DNR in the OR, Nov: 17
Donation after cardiac death, Oct: 18
Policies on disclosure of MD conflicts,
May: 24
EVIDENCE-BASED PRACTICE
EBP steps for CABG, Aug: 9
Interspinous process decompression, Jul:
(suppl)
Intervertebral disc replacement, Sep:
(suppl)
EYE SURGERY
HOSPITALS
Are infections inevitable?, Feb: 5
Most Wired hospitals lessons, Jan: 5
PA reporting infections, Jan: 25
May: 24
INFECTION CONTROL
Are infections inevitable?, Feb: 5
Biological indicators FAQs, Oct: 23
Chemical indicators FAQs, Jun: 20
Editorial, Feb: 3
Major study on surgical outcomes,
Aug: 21
INFORMATION SYSTEMS
Adding instrument tracking?, Aug: 14
Information systems ratings, Apr: 12
More wired OR supply chain, Aug: 13
Most Wired hospitals lessons, Jan: 5
Moving to online charting, Apr: 11
OR analyst: support periop leaders,
Aug: 17
Perfect OR inventory quest, May: 16
RFP for software, Apr: 14
RFP sample, Apr: 15
INFORMED CONSENT
CMS consent guidelines, Jan: 7
Informed consent guidelines revised,
Jun: 5
INNOVATION
Five-way kidney swap, Feb: 8
Managing OR inventory, May: 1
NOTES surgery innovation, Jul: 1
INSTRUMENTS - SEE SUPPLIES &
EQUIPMENT
JOB SATISFACTION
Job satisfaction, Oct: 14
JOINT COMMISSION
Editorial, Jun: 3
27
Flash sterilization readiness, Mar: 17 (correction, May: 18)
JCAHO survey readiness, Jan: 20
Joint Commission’s 2008 safety goals,
Aug: 16
Tissue standard, Feb: 15
Tissue tracking requirements, Feb: 1
Universal Protocol same for now, Aug: 5
LAW & LEGISLATION
FMLA and staffing, Apr: 17
FMLA facts, Apr: 18
Implant pricing bill, Dec: 5
LEADERSHIP
Good data to guide decisions, Sep: 19
Governance success factors, Jan: 11
Mentoring new leaders, Jun: 11
Nurse leader programs list, Jun: 8
OR director’s duties expand, Oct: 1
OR governance models, Jan: 10
Planning for future leaders, Jun: 1
MANAGEMENT
Manage with positive redirection, Jun: 23
MEDICARE – SEE CMS
MEDICATION ERRORS – SEE TREATMENT ERRORS
MEETINGS
Accountability key to survival, Jun: 15
Business management topics, Mar: 7
‘Carrot Principle’ as motivator, Aug: 10
Great leaders keep great staff, Apr: 5
‘Just culture’ for patient safety, Jul: 5
Managing Today’s OR Suite, Dec: 21
Managing Today’s OR Suite program,
Apr: insert
OR construction track, Feb: 7
Power of teams conference theme, Jan: 22
‘Resonant Leaders’, May: 7
NURSING SHORTAGE
OPERATING ROOMS
Are your ORs ‘efficient’?, Dec: 16
Lean thinking: OR processes, Mar: 1
MDs/Hospitals manage surgical services,
Nov: 1
Six practices for a lean OR, Mar: 10
‘Wasteology’ in the OR, Mar: 11
ORGAN TRANSPLANTATION
Editorial, Oct: 3
OR MANAGERS
2007 Salary/Career Survey, Oct: 1
28
Barbara Johnson, Manager of the Year,
Oct: 7
Competencies for OR management, Jun: 9
Opportunities in interim management,
Apr: 1
OR director’s duties expand, Oct: 1
ORTHOPEDICS
Bone cement complication, Feb: 30
Implant makers craft legal deal, Nov: 5
Implant pricing bill, Dec: 5
OUTCOMES - SEE QUALITY
PAIN
New findings on postop pain, Nov: 16
PATIENT RIGHTS
PATIENT SAFETY
Counts in general surgery, Dec: 11
Editorial, May: 3
Error reporting helps patient safety, Apr: 1
Aug: 16
Kids at highest med error risk, May: 11
OR medication safety, Jan: 17
Preop briefings boost safety, Jul: 1
Preop briefings for patient safety, Mar: 1
Preventing wrong surgery, Aug: 7
Sleep apnea risk assessment, Mar: 21
Timeout: bedside, Dec: 14
PATIENT SATISFACTION
PEER SUPPORT
PERSONNEL RETENTION
Magnet status aids staffing, Jun: 1
Mentoring new leaders, Jun: 11
PHYSICIANS
Nov: 1
POLICY
May: 24
PREOPERATIVE CARE
Cardiac screening revised, Nov: 23
Preop prep strategies, Feb: 1
Role of preop clinic, Feb: 14
VHA improves OR processes, Nov: 14
What works to smooth preop?, Feb: 10
PRODUCTIVITY
Are your ORs ‘efficient’?, Dec: 16
Logistics: learning from FedEx, Nov: 12
Parallel processing reduces OR time,
Feb: 18
Preop prep strategies, Feb: 1
Role of preop clinic, Feb: 14
PROGRAM PLANNING
PURCHASING
Accurate surgeon preference lists, Nov: 1
ASC supply cost data stories, Jun: 27
Jul: 20
OR inventory like a grocery store?,
May: 14
Selecting a GPO: checklist, May: 26
QUALITY
‘5S’: lean method to cut clutter, Mar: 15
Becoming a bariatric center of excellence,
Jan: 1
Major study on surgical outcomes,
Aug: 21
Postop protection from VAP, Jul: 15
What works to smooth preop?, Feb: 10
RECRUITMENT & RETENTION – SEE
PERSONNEL RETENTION
RESUSCITATION ORDERS
DNR policy elements, Nov: 18
REVENUE – SEE BUSINESS
RISK MANAGEMENT
Risk management vulnerability, Feb: 27
RULES AND REGULATIONS
CMS revises rules, Jan: 9
Outpatient quality reporting slated, Sep: 5
SAFETY – SEE ALSO PATIENT SAFETY
Aug: 16
SALARIES & BENEFITS – SEE ALSO SURVEYS
Annual salary/compensation, Oct: 9
Plans reward peak performers, Feb: 23
Salaries for high pressure work, Oct: 16
SCHEDULING & UTILIZATION
Nov: 1
SENTINEL EVENTS - SEE TREATMENT
ERRORS
SKILL MIX
OR skill mix holds steady, Sep: 11
SPINAL SURGERY
Advanced spine surgery center, Nov: 29
December 2007
Editorial, Nov: 3
Fusion evidence sparse, Mar: 5
Spine surgery in the ASC, Nov: 25
STAFFING
Editorial, Sep: 3
Orientation trends, Dec: 1
STERILIZATION & DISINFECTION
Biological indicators FAQs, Oct: 23
Chemical indicators FAQs, Jun: 20
Flash sterilization readiness, Mar: 17 (correction, May: 18)
SUPPLIES & EQUIPMENT
Jul: 20
GI endoscope benchmarking, Nov: 19
May: 14
Used equipment ‘Remedy’, Sep: 23
Weight of instrument sets, May: 5
SURVEYS
Annual salary/compensation, Oct: 9
ASC recruiting difficulty, Sep: 13
JCAHO survey readiness, Jan: 20
Job satisfaction, Oct: 14
Open staff positions, Sep: 9
OR annual budgets, Oct: 13
OR ratings on SCIP measures, Oct: 11
OR staff hiring, Sep: 10
OR staffing trends, Sep: 9
Recruiting difficulty, Sep: 7
Salaries for high pressure work, Oct: 16
Scope of job/title, Oct: 11
Use of overtime, Sep: 7
Use of travel/agency nurses, Sep: 7
Value analysis, Oct: 12
Who owns ASCs?, Feb: 29
TEAMS & TEAMBUILDING
Editorial, Jul: 3
Jun: 22
TECHNOLOGY
ECRI advises on cell phone use, May: 13
May: 14
TISSUE BANKS
TREATMENT ERRORS
Editorial, Jan: 3
Editorial, Mar: 3
Error reporting helps patient safety, Apr: 1
Kids at highest med error risk, May: 11
OR medication safety, Jan: 17
Root causes of surgical events, Apr: 8
Some errors no longer paid for, Oct: 5
TURNOVER TIME – SEE PRODUCTIVITY
VENDORS
RFP for software, Apr: 14
WASTE DISPOSAL
WORK REDESIGN
‘5S’: lean method to cut clutter, Mar: 15
Parallel processing reduces OR time,
Feb: 18
Planning for the worst, Aug: 1
WRONG SITE - SEE SURGICAL SITE
SURGERY
NOTES surgery innovation, Jul: 1
Surgical ‘Apgar score’, Mar: 9
SURGICAL CARE IMPROVEMENT PROJECT
Creating culture of teamwork, Mar
(suppl): 7
DVT prophylaxis, Mar (suppl): 26
Hair removal case study, Mar (suppl): 14
Hair removal changes, Mar (suppl): 13
Keeping OR patients warm, Mar
(suppl): 16
OR ratings on SCIP measures, Oct: 11
Postop protection from VAP, Jul: 15
Preventing VTE, Mar (suppl): 23
Quality reporting, Mar (suppl): 12
Right antibiotic at right time, Mar
(suppl): 8
SCIP overview, Mar (suppl): 4
SCIP: periop leader’s role, Mar (suppl): 5
Setting up beta-blocker protocol, Mar
(suppl): 20
Tighter glucose control, Mar (suppl): 10
VTE risk levels, Mar (suppl): 25
Warming protocols at two hospitals, Mar
(suppl): 19
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SURGICAL SITE
Timeout: bedside, Dec:14
Universal Protocol same for now, Aug: 5
SURGICAL TECHNOLOGIST
December 2007
29
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CARE SYSTEM
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30
December 2007
31
INTEGRATED MEDICAL SYSTEMS
At a Glance
Eye surgery errors
rare but serious
Errors in eye surgery are rare, happening in an estimated 69 cases out of 1 million. But consequences can be serious, a
new study finds. The most common error
was implant of the wrong lens, accounting
for 63% of mistakes. These errors most
often happened because lens specifications weren’t checked before the case.
The Universal Protocol, if followed,
would have prevented 85% of the errors,
say the authors, from Albany Medical
College, Albany, New York. The protocol, mandated by the Joint Commission,
requires steps to verify the surgical site.
In the analysis of 106 cases occurring
between 1982 and 2005, the wrong eye
was injected with anesthesia in 14 cases
(13%), and the wrong eye was operated
on in 15 cases (14%). In 8 cases, confusion involved the wrong patient or procedure. In 2 cases, the wrong tissue was
implanted.
The most severe injuries involved the
wrong implant or tissue.
The study led by John W. Simon, MD,
was reported in the November Archives
of Ophthalmology.
Orthopedic implant makers
post MD consulting fees
Orthopedic implant makers have
posted on their websites lists of the
physicians to whom they are paying consulting fees and the amounts. The postings are part of an agreement by the
companies with federal prosecutors in
September related to alleged kickbacks
to surgeons. Also posted are the agreements with prosecutors, which spell out
how the companies have agreed to handle consulting.
The lists of consultants and payments
are on websites of Zimmer, Smith &
Nephew, Biomet, DePuy Orthopaedics,
and Stryker.
Excess disinfectants harm
electronic equipment
Four federal agencies issued a public
health notice Nov 2 cautioning about
hazards associated with inappropriate
use of liquid disinfectants and cleaners
on electronic medical equipment.
In the past 2 years, the agencies have
learned of equipment fires and malfunctions and health care worker burns due
to corrosion of circuits caused by disinfectants or cleaners that penetrated
equipment housings. Examples of affected equipment are infusion pumps, ventilators, and sequential compression
device pumps. The notice includes recommendations.
The notice was issued by the Food and
Drug Administration, Centers for Disease
Control and Prevention, Environmental
Protection Agency, and Occupational
Safety and Health Administration.
—www.fda.gov/cdrh
Most invasive MRSA infections
related to health care, CDC
reports
Invasive infections caused by
Methicillin-resistant Staphylococcus aureus
(MRSA) may be twice as common as
thought, and most—85%—are associated
with health care, according to a report by
the CDC:
In the study:
• 58% of invasive MRSA infections
occurred outside the hospital but
among persons with risk factors for
MRSA, such as hospitalization within
the past year
• 27% were hospital-onset
• 14% were community associated (had
no documented health care risk factor). The remaining 1% could not be
classified.
The researchers estimate 94,360
MRSA infections occurred in the US in
2005, and 18,650 were associated with
death—exceeding deaths from AIDS,
Parkinson’s disease, emphysema, or
homicide.
MRSA infections and deaths were
higher for the elderly, African-Americans,
and men.
—Klevens R M, Morrison M A, Nadle J.
JAMA. 2007:298:1763-1771.
First certification for
bariatric nurses
The first certification program for
bariatric nurses has been established by
the American Society for Metabolic &
Bariatric Surgery (ASMBS). To be eligible
for the certified bariatric nurse (CBN)
examination, an RN must have at least 2
years of experience in caring for morbidly obese and bariatric surgery patients.
Exams are offered twice a year through a
week-long computer-based testing program.
Information and registration for the
exam are available on the ASMBS website. v
—www.asbs.org
Periodicals
P O Box 5303
Santa Fe, NM 87502-5303
32
December 2007

A Lateral violence: Why it’s serious and what OR managers can do

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